SUSTAINING HEALTH GAINS –

BUILDING SYSTEMS

Health Systems Report to Congress

October | 2009 
SUSTAINING HEALTH GAINS –

BUILDING SYSTEMS 

Health Systems Report to Congress

USAID 

Washington, DC

October | 2009

Health Systems Report to Congress 3

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

2. Health Systems Strengthening in Low-income Countries . . . . . . . . . . . . . . . . . . . . . . . . . .19

3. Health Systems Strengthening in Post-conflict and Conflict Countries . . . . . . . . . . . . . . .25

4 . Health Systems Strengthening in More Advanced Developing Countries . . . . . . . . . . . . .29

5. Best Practices Research and International Technical Collaboration . . . . . . . . . . . . . . . . .35

6. Funding for Health Systems Strengthening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

7. Measuring Progress in Health Systems Strengthening . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

8. Conclusion: The USAID Approach to Health Systems Strengthening . . . . . . . . . . . . . . .47

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Sources for Country Statistical Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Annexes

A. Illustrative Health Systems Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

B. Summary of USAID-sponsored Health Systems Research and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

C. Implementing the WHO/PEPFAR Task-shifting Recommendations and Guidelines . . . . . . . . . . . . . . . . . . . . . . . .59

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

TABLE OF CONTENTS
4 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 5

The Omnibus Appropriations Act for 2009 (HR1005, 2009)

contains the following statement: 

“USAID is directed to provide a report to the Committees

on Appropriations not later than 180 days after enactment

of this Act on current efforts to strengthen health systems,

including spending by program, and progress made. The report

should include a summary of OGAC’s plans to implement

the World Health Organization (WHO) task shifting guidelines

and a summary of the health care infrastructure that will be

built with HIV/AIDS funding in this Act.” 

According to the World Health Organization (WHO), a health

system consists of all organizations, people and actions whose

primary intent is to promote, restore or maintain health. This

includes efforts to influence determinants of health as well as

more direct health-improving activities. A health system is

therefore more than the pyramid of publicly owned facilities

that deliver personal health services. It includes, for example,

a mother caring for a sick child at home; private providers;

behaviour change programs; vector-control campaigns; health

insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example,

encouraging the ministry of education to promote female

education, a well known determinant of better health

(WHO, 2007, p. 2).

Health systems strengthening (HSS) is defined as any array

of initiatives and strategies that leads to better health through

improvements in one or more of the health system’s functions

measured by increased access, coverage, quality, or efficiency.

It also implies a measureable improvement in performance

that is sustained beyond the period of donor assistance. 

Strengthening the health systems of developing countries is a

central goal of USAID health programming. Achieving this

goal is critical to sustaining improvements in outcomes in

health- or disease-specific areas and is a significant factor in

supporting overall development in partner countries. Current

efforts to strengthen health systems fall along a spectrum

ranging from: 

• health system improvements that mainly address a diseaseor health-specific area, such as effective drug management

systems for maternal and child health and high-quality

laboratories for tuberculosis (TB) diagnosis, to

• improvements that benefit the whole system, such as

increasing health system ability to persuasively promote

good health practices that prevent disease and to improve

tracking a country’s health expenditures. 

In both specific and broad systems improvements, USAID’s

aim is to build durable improvements that develop long-term,

sustainable capacity to affect the health of their people.

Health systems strengthening (HSS) and disease- and healthspecific intervention areas are mutually reinforcing approaches

to health sector development. The success of USAID in assisting

countries to improve the health status of their population could

not have occurred if those programs had not also strengthened

the countries’ health systems. This complementary relationship

of systems strengthening and health-related interventions

applies, for example, in reducing under-5 mortality and maternal

deaths, increasing detection and treatment rates for TB, and

decreasing fertility rates. USAID support for surveillance systems

for monitoring the threat of infectious diseases, or for logistics

systems for stocking and distributing contraceptives as part of

TB or family planning programs, can have a broad impact on

the health system as a whole. USAID recognizes the importance of achieving sustainable results in disease-specific work

and also strengthening health systems and looks for opportunities to work on broader, cross-cutting health systems issues. 

The World Health Organization (WHO) has defined six core

functions, sometimes called building blocks, of a working

health system: service delivery; human resources; information;

medical supplies, vaccines, and technology; health financing;

and governance and leadership (WHO, 2007). USAID assistance strengthens health systems – be it within disease-specific

programs, across multiple health areas, or across the entire

system. USAID assistance addresses both the demand and

supply sides of health programs, focusing on improving understanding of why people do not adopt behaviors that promote

EXECUTIVE SUMMARY
6 Sustaining Health Gains – Building Systems

health and prevent disease, and then planning, implementing,

and evaluating social and behavior change communications.

USAID assistance also looks at what is keeping people from

accessing, affording, and receiving quality care, and develops

interventions to address these constraints. These interventions address one or more of the six core functions of the

health system. 

Country Experiences 

in Health Systems Strengthening

Given the complexity of HSS interventions and the need to

tailor interventions based on country situations, the global

community has yet to reach a consensus on internationally

approved indicators and benchmarks to measure HSS. The

lack of consensus surrounding a set of tested and accepted

indicators related to health systems hinders efforts to track

progress and demonstrate evidence-based results of investments in health systems. 

Despite the fact that the international community is still developing feasible, valid indicators of progress in health systems, we

do have substantial evidence as indicated below of improved

functioning of health systems and the link to health impact. 

The country examples in this report represent a cross-section

of USAID activities in different country contexts – low income,

post-conflict, and more advanced developing countries –

across all regions where USAID works. They were selected to

show where and how health systems have been strengthened

to have the greatest possible impact on the population’s health.

The country examples demonstrate how funding directed at

a specific health or disease area can accomplish specific health

objectives and strengthen systems at the same time. Each

country example includes a snapshot of current health statistics,

some background on USAID’s contribution to the long-term

development of the health system, and an illustrative example

from the current program.

Chapter 2 demonstrates that even in the low income countries,

where human capital is strained, and infrastructure is weak,

countries can find creative solutions to health systems problems that were accompanied by clearly identifiable positive

results in public health impacts. The work described in Rwanda,

Ethiopia, Kenya, Kyrgyzstan, Haiti, and Yemen shows USAID’s

contributions to strengthen underdeveloped health systems

and the health impact these contributions have had. USAID’s

support for decentralization of Health Ministry functions in

Rwanda, for example, likely played a role in the drop in

under-5 mortality from 192 to 103 deaths per 1,000 live

births. HSS efforts in Ethiopia, including those on health

financing and human resources, paralleled a reduction in

under-5 mortality from 166 to 123 deaths per 1,000 live

births and a 23 percent decrease in maternal mortality. In

Kyrgyzstan, USAID supported integrated service delivery and

improved quality of care, when the country experienced a

drop in infant mortality from 63 to 27 per 1,000 live births.

USAID’s work in Haiti to reestablish the public sector’s ability

to deliver basic services accompanied significant increases in

immunization rates (from 21 percent to 63 percent), and in

the proportion of deliveries attended by skilled personnel

(from 17 percent to 26 percent).

Chapter 3 discusses health system strengthening programs in

post-conflict countries, where the capacity of governments to

provide health services is usually weak. To make an impact on

health status, the basic elements of a health system, such as

financing, human resources, and pharmaceutical and commodity

provision, must be built or rebuilt as the country transitions

from relief to development. These complicated changes include

the transition of finance, leadership, operations, and ownership.

In post-conflict settings, government leaders typically express

an urgent need to prove their legitimacy by showing citizens

that they can meet basic needs. The work described in

Southern Sudan, Liberia, and Afghanistan illustrates USAID’s

contribution to those countries’ transitions. The work is carried

out under national policy frameworks that further legitimize

the government, improve health outcomes, and put the country

back on the path of development. System strengthening in

post-conflict settings can have significant public health impact:

In the case of Liberia, under-5 mortality has dropped from

219 in 1994 to 110 in 2007 during the time the country

transitioned to a stable government. In Afghanistan, a strategy

of scaling up direct service delivery with nongovernmental

organizations, improving workforce capacity, and providing

technical leadership for health sector governance made possible

an increase in the percentage of the population with access

to basic health service from 9 percent in 2000–2003 to 84

percent in 2006–2008. 

Chapter 4 looks at more advanced developing countries whose

health systems, while stronger, continue to face challenges. In

these countries, USAID focuses especially on assisting countries

to make health service access more equitable and to develop

sustainable health systems. Even these countries may struggle

to provide adequate health services to their poor, disadvantaged, or remote populations, exacerbating inequities in health
Health Systems Report to Congress

and nutrition as well as dissatisfaction with political institutions.

The activities described in Peru, Honduras, Armenia, Egypt,

South Africa, Nicaragua, and Georgia show USAID’s contribution

to addressing problems within each of the health systems

functions as they move toward a sufficient level of quality

and coverage. As countries progress, both national and local

governments gain the ability to evaluate health systems

performance and adjust programs to sustain improvements

in health outcomes, especially for the poorest underserved

populations. In Armenia, for example, USAID helped introduce

more equitable and efficient health financing systems and a

Basic Benefits Package that provides free maternity services

for all Armenians. Subsequently, the rates of postpartum

hemorrhage, the main cause of maternal deaths, fell more

than 60 percent between 2005 and 2008. 

Research and International 

Technical Collaboration 

USAID conducts health systems research and evaluations to

identify, test, and facilitate best practices that reduce the burden of disease attributable to the major causes of mortality

and severe morbidity. USAID health systems research meets

four criteria: relevance to success of health interventions in

HIV/AIDS, malaria, tuberculosis, reproductive health and famil

planning, maternal and newborn health, and nutrition; potential

to improve access, quality, and/or affordability; ability to achieve

demonstrable and measurable improvement within three to

five years; and suitability for sustained use in low-resource

settings. A listing of illustrative HSS interventions by core

function (building block) is given in Annex A; a listing of

research accomplishments is given in Annex B.

USAID advances research in the six core functions of HSS.

Through international technical collaboration, USAID supports the adoption by WHO and other relevant bodies of

international standards for best practices in health systems

interventions and indicators to measure their progress. In

addition, USAID helps build consensus around health systems

policy issues. The innovative collaboration of U.S. President’s

Emergency Plan for AIDS Relief (PEPFAR), USAID, and the

WHO led to the development of a global approach to task

shifting (see Annex C). 

Funding for Health Systems Strengthening

Because USAID takes a development approach to all health

programming, much of what is done in the health sector is

designed to develop and strengthen local institutions and

capabilities. The Foreign Assistance Framework1 used by

y

USAID to track funds, however, was not set up to track

cross-cutting health systems activities, although it is possible to

categorize some health sector assistance as part of the six

functions, or building blocks popularized by WHO. 

Based on an analysis of funding attributed to the Elements of

the Foreign Assistance Framework, USAID has identified a

1. The U.S. Department of State/USAID Foreign Assistance Framework

tracks activities and funding according to an established set of disease-specific and health program-specfic elements that capture and track Congressional

appropriation sub-accounts and directives. The framework provides detailed

information on programs and funding for the health elements – maternal

and child health (MCH), malaria, TB, family planning and reproductive health,

avian influenza, water supply and sanitation, HIV/AIDS, and other public

health threats. Within each of the elements, sub-elements track more specific

activities that contribute to the element. The main sub-elements of the MCH

element, for example, involve issues in maternal and child morbidity and

mortality such as treatment of child illness, birth preparedness and maternity

services, and newborn care and treatment.

7

Table 1. Health Systems-related Funding 

(all accounts except HIV/AIDS and Avian Influenza)

(Cross-cutting Health System Functions within All Health Elements)

Health Systems Functions Total FY08 

Planned Funding

AMR/Pharmaceutical

Management/Medical Supplies $336,970,287

Information $115,730,519

Governance/Finance/Policy $220,267,753

Other (health systems-related activity) $148,983,507

Total $821,952,512

Table 2. Service Delivery/Human Resources Functions

Within Each Health Element

(The current framework cannot track the proportion of these funds that related

directly to HSS activities)

Total FY08 Service Delivery/Human Resources Planned Funding

$79,960,819

$123,312,981

 $460,664,970

Other Public Health Threats $30,413,064

$211,839,861

$906,191,965

Note: Tables do not include funding for HIV/AIDS or Avian Influenza.
8 Sustaining Health Gains – Building Systems

total of $821,952,512 of $1,728,144,477 appropriated in FY

2008 (see Table 1) that can be classified in one of the six

health systems functions. This amount includes funding from

all accounts for all elements except HIV/AIDS and avian and

pandemic influenza. (HIV/AIDS funding is analyzed separately,

below, and Avian and Pandemic Influenza funding is emergency

funding meant for the immediate response to the pandemic.)

In addition, another $906,191,965 is classified as service delivery

and human resources (see Table 2). At this time, USAID

cannot identify specific health systems activities for these

funds, but this will become possible as specific health systems

indicators and tracking tools are developed.. 

It should be noted that the funding represented in the charts

is not in addition to the funds appropriated for health- or

disease-specific areas, but rather another way of representing

this same funding in terms of the functions of the health system. 

HIV/AIDS

As of end of FY 2008, USAID had implemented approximately

57 percent of the interagency PEPFAR bilateral funding. In FY

2009, total bilateral enacted funds for PEPFAR amounted to

$5,462 billion, to date, approximately $2.4 billion implemented

by USAID. At USAID, HIV/AIDS programs engage in

strengthening health systems through:

• focused investments necessary to achieve HIV/AIDS

prevention, care, and treatment goals; 

• investments in activities with additional non-disease specific

impacts that benefit the overall health system; and

• targeted leveraging with other donors or U.S. Government

(USG) partners.

Based on a separate analysis, OGAC has determined the

following investments in HSS for FY 2009 in 31 countries

where PEPFAR money is implemented by all USG agencies.

Drawing on Country Operational Plans, the analysis below

reflects funding for HSS across all PEPFAR implementing

agencies in the Elements listed, totaling $922 million. The

$922 million reflects an initial estimate, calculated in February

of 2009; OGAC anticipates HSS investments to increase in

FY 2009 once all resources have been programmed in the

Country Operational Plans (COPs). Plans for data collection

in the future should allow for Agency attribution. 

• Logistics and commodities support: $228.5 million

Below is an estimate of PEPFAR investments in 

onstruction and rehabilitation, especially laboratory

nfrastructure, across all USG agencies, totaling

201,300,000 (see Table 2, below). OGAC anticipates

Y 2009 investments to increase once all resources

ave been programmed in the Country Operational

lans (COPs).

c

i

$

F

h

P

TABLE 1: USAID CONSTRUCTION AND REHABILITATION 

IN HEALTH FUNDING BY PROGRAM LOCATION AND REGION 

(USD FY 2008)

Location Region Total

Africa $26,234,924

Asia $16,918,560

Field Mission Europe & Eurasia $4,729,648

Latin American 

and the Caribbean $8,823,986

Middle East $59,075,192

Field Mission Subtotal $115,782,310

Centrally-Managed Field Programs $2,041,000

GRAND TOTAL $117,823,310

TABLE 2: PEPFAR INVESTMENTS IN 

CONSTRUCTION AND REHABILITATION 

(USD FY 2009)

Category Total

Laboratory Infrastructure $172,600,000

USG-managed 

Construction Projects $28,700,000

GRAND TOTAL $201,300,000

Construction and Rehabilitation

USAID assistance can include construction and rehabilitation of health facilities where needed and where

support is not available from other donors. A total of

$117,823,310 in construction and rehabilitation was

provided during FY 2008 from all sources and appropriation accounts, except for the PEPFAR program (see

Table 1, below). Of significance, a large portion of the

spending in the Middle East region is supporting the

construction of essential health facilities.
Health Systems Report to Congress

• Strategic information: $138.2 million

• Human resources for health: $379.9 million

• Program activities attributable to other HSS: $175.7 million

PEPFAR also invested in infrastructure and construction in FY

2009 (see page 8).

Measuring Progress 

in Health Systems Strengthening 

USAID currently collaborates with Health Metrics Network,

WHO, and other research centers in the United States and

overseas devoted to the development of better consensus

health systems indicators and tools to measure progress.

Many valid indicators exist for tracking health systems, but

there is no standard set of indicators collected by one or

more countries that could facilitate the analysis necessary to

demonstrate evidence-based results of investments in health

systems. USAID and its partner organizations already have

developed a variety of methods for measuring the individual

areas of health systems strengthening, including:

• The Health Systems Assessment Approach guides a rapid,

comprehensive review of the health system’s six functions

to inform the development of country and USAID mission

health strategies. Health Systems Assessments have been

conducted in Benin, Angola, Nigeria, Vietnam, Pakistan,

Southern Sudan, and Namibia.

• The Health Systems Database compiles key health systems

indicators from existing online data sources (e.g.,

Demographic and Health Surveys, WHO Statistical

Information System, World Bank World Development

Indicators) to produce data-driven country health systems

profiles and analytical tools.

• Health Systems Dashboards are a feature of the Health

Systems Database and facilitate benchmarking country

health systems against their regional and income-group

peers. These visual representations of health systems indicators guide users to areas of health system functions that

need further analysis. 

The USAID Approach 

to Health Systems Strengthening

The long-term sustainability of partner country programs that

address child, maternal and reproductive health; that control

major diseases,2 and that reduce abortion will depend in

large measure on the capacity of partner country public and

private health systems to produce high quality, accessible, and

efficient services. The challenge for USAID and the partner

countries with which it works is to identify and strengthen

those parts of health systems whose strengthening is most

critical in the local context to addressing the major local

drivers of human health, collaborating with partner country,

private sector, and other donors to reach a minimum standard

across each core function. 

While many kinds of activities can contribute to strengthening

health systems, USAID uses a strategic approach that is based

on extensive evidence and experience to target the most

critical health systems function needs and elements. USAID

helps countries move toward sustainability through continued

integration of disease-specific interventions and information

to promote health and prevent disease into the broader

health system – increasing efficiency while protecting progress

on disease-specific interventions. 

9
10 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 11

AIS

AMR 

AIDS Indicator Surveys

Antimicrobial Resistance

ART

DOTS

EHP

EPHTI

FY

Antiretroviral Therapy

Directly Observed Treatment, Short Course

Emergency Hiring Plan

Ethiopian Public Health Training Initiative

Fiscal Year

GAVI Global Alliance for Vaccines and Immunization

GHI Global Health Initiative

GHIN

GHWA

Global HIV/AIDS Initiatives Network

Global Health Workforce Alliance

HAPSAT

HMN

HIV/AIDS Program Sustainability Analysis Tool

Health Metrics Network

HRH Human Resources for Health

LLIN

MCH

Long-lasting Insecticide-Treated Nets

Maternal and Child Health

M&E

NGO

OGAC

Monitoring and Evaluation

Nongovernmental Organization

U.S. Office of the Global AIDS Coordinator

PEPFAR

PHE

U.S. President’s Emergency Plan for AIDS Relief

Public Health Evaluation

PMTCT Prevention of Mother-to-Child Transmission of HIV

SCMS

TB

Supply Chain Management Systems

Tuberculosis

USAID

USG

U.S. Agency for International Development

U.S. Government

WHO World Health Organization

ACRONYMS AND ABBREVIATIONS
12 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 13

The Omnibus Appropriations Act for 2009 (HR1005, 2009)

contains the following statement: 

“USAID is directed to provide a report to the Committees

on Appropriations not later than 180 days after enactment

of this Act on current efforts to strengthen health systems,

including spending by program, and progress made. The report

should include a summary of OGAC’s plans to implement

the World Health Organization (WHO) task shifting guidelines

and a summary of the health care infrastructure that will be

built with HIV/AIDS funding in this Act.” 

According to the World Health Organization (WHO), a health

system consists of all organizations, people and actions whose

primary intent is to promote, restore or maintain health. This

includes efforts to influence determinants of health as well as

more direct health-improving activities. A health system is

therefore more than the pyramid of publicly owned facilities

that deliver personal health services. It includes, for example,

a mother caring for a sick child at home; private providers;

behaviour change programs; vector-control campaigns; health

insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example,

encouraging the ministry of education to promote female

education, a well known determinant of better health

(WHO, 2007, p. 2).

Health systems strengthening (HSS) is defined as any array

of initiatives and strategies that leads to better health through

improvements in one or more of the health system’s functions

measured by increased access, coverage, quality or efficiency.

It also implies a measureable improvement in performance

that is sustained beyond the period of donor assistance. 

Strengthening the health systems of developing countries is

a central goal of USAID health programming. Achieving this

goal is critical to sustaining improvements in outcomes in

health- or disease- specific areas, and is a significant factor in

supporting overall development in partner countries. Current

efforts to strengthen health systems fall along a spectrum

ranging from:

• health system improvements that mainly address a diseaseor health-specific area, for example, better quality laboratories for tuberculosis (TB) diagnosis, to 

• improvements that benefit the whole system, for example,

increasing health system ability to persuasively promote

health and prevent disease, and to improve tracking a

country’s health expenditures. 

In both specific and broad systems improvements, USAID’s

aim is to build durable improvements which develop longterm, sustainable capacity to affect the health of their people.

Health systems strengthening (HSS) and disease- and healthspecific intervention areas are mutually reinforcing approaches

to health sector development. The success of USAID in assisting

countries to improve the health status of their population could

not have occurred if those programs had not also strengthened

the countries’ health systems. This complementary relationship

of systems strengthening and health-related interventions

applies, for example, in reducing under-5 mortality and maternal

deaths, increasing detection and treatment rates for TB, and

decreasing fertility rates. USAID support for surveillance

systems for monitoring the threat of infectious diseases, or

for logistics systems for stocking and distributing contraceptives

as part of TB or family planning programs, respectively, have

an impact on the health system beyond the specific disease

or health area. USAID recognizes the difficulty of achieving

sustainable results in disease-specific work without also

strengthening health systems, and looks for opportunities to

work on broader, cross-cutting health systems issues. 

The World Health Organization (WHO) has defined six core

functions, sometimes called building blocks, of a working

health system: service delivery; human resources; information;

medical supplies, vaccines, and technology; health financing; and

governance and leadership (WHO, 2007). USAID assistance

strengthens health systems – be it within disease-specific

programs, across multiple health areas, or across the entire

system. USAID assistance addresses both the demand and

supply sides of health programs, focusing on improving understanding of why people do not adopt behaviors that promote

1. INTRODUCTION
14 Sustaining Health Gains – Building Systems

health and prevent disease, and then planning, implementing,

and evaluating social and behavior change communications.

USAID assistance also looks at what is keeping people from

accessing, affording, and receiving quality care, and develops

interventions to address these constraints. These interventions address one or more of the six core functions of the

health system. 

Many countries where USAID works have integrated primary

health care services that enable USAID to bring together

maternal and child health and nutrition, malaria, and, in

some cases, HIV/AIDS prevention and treatment programs

to strengthen the whole primary health care system. In other

cases, USAID is able to leverage other country and donor

efforts to address system-wide bottlenecks to achieve the

broadest possible effect on quality, accessibility, or affordability

of health services to improve people’s health. 

Where and how USAID works with each country in

strengthening its health system depends upon the country

context, health priorities, and roles of other donor partners.

HSS activities can have especially high impacts in countries

with strong government ownership, commitment, and implementation capacity, and with partners willing to coordinate

resources and scale up cross-cutting initiatives. HSS activities

also can be effective in many of the more challenging country

contexts where USAID works. 

Challenges Facing Health Systems 

in Developing Countries

Despite impressive gains, health systems in many developing

countries remain weak, as evidenced by wide gaps in three

key indicators: access, quality of care, and affordability.

Significant inequities in health outcomes lie hidden beneath

national level indicators. Many rural and marginal urban areas

have little or no access to the most basic services or essential

medicines. Where services or health supplies are present,

financial constraints often force families and individuals to delay

or go without care and preventive services. Even when available,

services often are inadequate due to poor management of

workers or buildings, departure from evidence-based standards

and guidelines, and lack of data to make the right decisions

on priorities and allocation of resources. Specifically:

• Although the health workforce represents about 70 percent

of the cost of health care, management of human resources

in developing countries is weak. Producing more health

workers is an important and worthwhile investment in

many countries, and countries also can make better use of

the human resources that they have. 

• An estimated 30 percent of the world’s population lacks

regular access to medicines and other essential health

supplies. This figure rises to over 50 percent in the poorest

areas of Africa and Asia. Supply systems – from forecasting

and procurement to warehousing and distribution – suffer

from inadequate resources, inefficient system designs and

procedures, ineffective information and reporting systems,

and weak monitoring and supervision. Many systems are

ill-equipped to handle the rapidly growing volumes and

kinds of health products that they must manage. 

• Health programs are further challenged by the need to

ensure that medicines are of assured quality and safety

and are used appropriately by providers and consumers.

Health systems with inadequate regulatory capacity are

ill-equipped to control the entry of counterfeit medicines

and substandard products into the marketplace.

Inappropriate medicines use and the presence of poorquality medicines contribute to the emergence of drug

resistance and the need to use more costly second-line

medicines with longer duration of treatment for patients. 

• An estimated 180 million people in developing countries

suffer from financial catastrophe because of the cost of

health care. The root causes are high out-of-pocket

expenditures and scant availability of financial subsidies and

a viable insurance scheme. Many countries lack the public

financial management capacity to ensure timely budgeting

and adequate predictability in receipt of funding. As programs grow larger and more complex, many lack systems

and trained staff to manage and disburse funds to keep

pace. Expanding credit and other financing to private

health sector services to improve service quality and

access can complement public health services; increase

revenues from those who can afford to pay, thereby

freeing up public sector resources to serve the poor;

and achieve greater public health outcomes.

• Few developing countries have sufficiently strong and

effective health information systems to permit identification

of problems and needs and adequate monitoring of progress

toward their health goals. They are unable to make databased decisions on health policy and to allocate optimally

scarce resources. 
Health Systems Report to Congress

• Weak leadership and governance capacity limits countries’

efforts to design and implement effective health sector

strategies that incorporate the views and needs of individual

citizens, civil society, and private sector organizations. These

weaknesses lead to poorly managed, unregulated, corrupt

and under-funded health systems, resulting in unequal and

regressive distribution of resources that limits the availability

of basic health care. 

• Much of the service delivery in developing countries is of

poor quality, uses inefficient practices, and does not follow

evidence-based standards, thereby not taking advantage of

quality improvements that have proved highly effective in

even the poorest health systems. When surrounded by

poor-quality services, citizens may not know to demand

improvements. Further, people often do not have access to

persuasive, culturally sensitive information that would help

families practice lifesaving behaviors that promote health,

prevent disease, and encourage health-seeking behaviors. 

The Growing International Importance 

of Health Systems Strengthening

While USAID has provided leadership for more than three

decades to find and apply innovative solutions to health

systems problems – as discussed throughout this report, for

much of that period, USAID has collaborated with many

partners in the international community. Attention to and

funding for HSS, including in USAID, has grown substantially

in recent years. Donors, partner countries, and global health

partnerships recognize that the success of large-scale diseasespecific initiatives depends on effective health systems, and

the focus on health systems improves aid effectiveness, sustainability, and long-term predictable funding. Multilateral and

international technical agencies play a direct, catalytic role in

HSS in areas such as funding, knowledge management, and

global priority-setting. Wherever possible, USAID aligns programs to leverage the work of other agencies for comprehensive and coordinated investment in country HSS. Often,

USAID provides the technical assistance to make the more

significant financing provided by other partners most effective.

WHO plays a key role in weighing the evidence for global

standards and guidelines for the health sector, including those

for health systems interventions. WHO’s network of 193

member states and six regional offices facilitates the spread of

lessons and evidence on HSS. The World Bank’s health strategy

features HSS as its highest priority area, offering financial support to countries across all six health systems core functions,

especially in health financing, governance, and medicines. The

Global Alliance for Vaccines and Immunization (GAVI) and the

Global Fund to Fight AIDS, Tuberculosis and Malaria (Global

Fund) now put significant direct funding into country activities

that address health system constraints and weaknesses. Several

global health partnerships and task forces have formed to

address a specific health system component, including the Global

Health Workforce Alliance (GHWA), the Health Metrics

Network (HMN), the International Health Partnership+,

and the Taskforce on Innovative International Financing for

Health Systems.

Many member countries of the Organization of Economic

Co-operation and Development, the European Union, and

many private foundations provide support for HSS and collaborate with USAID’s efforts in this area. Several bilateral

country donors and foundations have spearheaded initiatives

related to specific health systems problems. For example, the

UK Department for International Development and several

partners launched a medicines transparency initiative to

address the problem of substandard and counterfeit drugs.

The Norwegian Agency for Development (NORAD) and

several partners support a special program to adapt methods

of performance-based management to health programs.

NORAD, the Canadian International Development Agency,

and the Swedish International Development Cooperation

Agency, among others, support global initiatives to strengthen

health systems.

The Japan International Cooperation Agency provides HSS

assistance to several countries. Germany and France have led

global consultations on ways to implement insurance systems

to increase access of low-income groups to affordable health

services. The Bill & Melinda Gates Foundation supported the

creation of key health systems initiatives, such as GHWA and

HMN. The Rockefeller Foundation supported an extensive

study and learning process to identify the causes of the looming human resources crisis in the health sector, leading to the

creation of GHWA and a multi-donor, decade-long effort to

find remedies to human resource problems.

USAID Approach to Strengthening 

the Core Health Systems Functions 

USAID health programs look at what is keeping people from

accessing, affording, and receiving quality care, and develop

interventions to help address these constraints. These interventions address one or more of the six core functions of

the health system in ways that will enable countries to sustain

15
16 Sustaining Health Gains – Building Systems

gains in health outcomes beyond the period of donor assistance. Specifically for each of the core functions:

• Human resources. USAID helps countries to improve

human resource management, ensuring they have the right

number, mix, and distribution of competent, efficient, and

responsive staff and volunteers. 

• Medical supplies, vaccines, and technology. USAID helps

countries to ensure equitable, timely, and consistent access

to essential products and technologies – including contraceptives, vaccines, and medicines of assured quality, safety,

efficacy, and cost-effectiveness – and the scientifically

sound, cost-effective use of these commodities. 

• Health financing. USAID helps countries mobilize resources

to pay for health needs from reliable, sustainable sources;

pool these resources efficiently and equitably; and allocate

them in ways to optimize impact, promote efficiency, and

enhance equity. This includes expanded health insurance,

community-based insurance; performance-based financing,

credit, and targeted subsidies. 

• Information. USAID helps countries develop their capacity

for the production, analysis, dissemination, and use of relevant,

reliable and timely health information for evidence-based

policy development, resource allocation, program planning

and management, advocacy, and community participation. 

• Leadership and governance. USAID works with countries to

increase the oversight and accountability of the governance of the health system and the participation of citizens, civil society, and the private sector as responsible

actors in its performance. USAID works also to improve

the leadership and management skills of health sector staff

to better plan and use resources.

• Service delivery. USAID assists countries to deliver proven

health interventions efficiently to prevent and treat illness,

promote healthy behaviors, to improve the quality of

service delivery, and to measure impact. 

Community Communications Involvement

Communications and community involvement and participation

are key ingredients to well-functioning health systems. A health

system cannot be considered effective if it is not proactive in

providing culturally sensitive and persuasive information to its

citizens and communities on the determinants of health and

disease, as well as responding to citizen and community

demands to be educated consumers of healthcare. Community

participation, including that of the media, nongovernmental

organizations (NGOs), faith-based organizations, and other

agents of civil society, engages individuals and communities to

make more informed decisions and take more responsibility

for their own health and for that of their families; empowers

communities to be active participants in both the direction of

health-improving activities and the delivery of health care

services; and creates an enabling environment to foster and

support positive health behaviors, both individually and collectively. An individual’s and community’s attitudes, perceptions,

and desires regarding health are essential inputs to a health

system, cutting across the entire framework. Community and

communication activities are an integral part of USAID’s

HSS efforts. 

Equity and How We Address It

Well-functioning health systems deliver high-quality health

services throughout the population. Inequities in health outcomes indicate weaknesses in the health system. Inequity

based on geography – urban versus rural, for example –

indicates an inadequate availability of health services. Inequity

based on culture – indigenous versus non-indigenous –

indicates the health services are not responsive to all groups.

Inequity based on wealth indicates that the cost of receiving

care – including costs associated with travel to the place of

health service delivery as well as user fees – is preventing

poorer people from accessing the care they need and not

protecting them from the risk of having to pay for catastrophic

costs of illnesses. Programs across the six health systems

functions address system failures in equity and narrow the

gaps in health outcomes among different population groups.

Additionally, waste and inefficiencies within a health system

hinder the ability to direct resources toward pro-poor policies.

USAID programs assist countries to target health resources

to all underserved population groups. When disparities exist

between high- and low-income populations, for example,

USAID assists governments to develop services and systems

that are responsive to all citizens. 

Sustainability of Health Gains

USAID works with countries to design programs that can

sustain gains in health. Some of the elements of sustainability

are: ensuring country ownership, encouraging community

involvement and work with the media, using proven interventions, analyzing initial investments and recurrent costs,

expanding the role of the unsubsidized private sector in the
Health Systems Report to Congress

delivery of health products and services, and strengthening

management capacity. For example, while a health system

could be strengthened by providing salary supplements, the

effect lasts only as long as donor funding. On the other hand,

training a clinician or a trainer of clinicians can improve performance for years. The impact of assisting a country to

design a community-based health insurance plan, a drug regulatory policy, a management information system, or social and

behavior change programs is long lasting. 

Effective and sustainable strategies for strengthening health

systems require leadership and commitment from, among

others, partner country governments, health service

providers, community workers, and NGOs. Introducing new

concepts or designs into existing health systems challenges

old ways of doing things and is never an easy task. Shifting

tasks to lower-level providers or using performance-based

payments, for example, require high levels of country ownership to be successful (see further discussion of task shifting in

Annex C, below). 

Creating strategies that address the health system’s ability to

reduce inequities and reach the poorest and most marginalized populations is especially challenging. Many countries find

that using the available knowledge and tools, it is extremely

difficult to implement successful pro-poor policies and build

public health and curative care programs that are fully

responsive to the poor. 

For example, catastrophic costs of illness due to expensive

hospital stays and treatments are not only a risk for families,

but also may drain public resources needed to subsidize

essential health services to the poorest of the poor. Waste

and inefficiencies within a health system can hinder the ability

to direct resources toward pro-poor policies. Inadequate

understanding of the determinants of healthy behaviors for

individual ethnic and cultural groups, especially the poor, may

cause investments in lifesaving health services to go underused.

USAID works with countries to understand these challenges

to sustainability and find more effective approaches to

improving program effectiveness. 

Investing in Infrastructure 

Building the physical health system infrastructure, such as

constructing or rehabilitating health facilities, installing communications infrastructure, and providing vehicles, is an important

element of HSS, particularly in post-conflict countries.

Strengthening health system infrastructure by itself, however,

does not address all the bottlenecks described above. USAID

engages in new construction only under special circumstances, and USAID field projects rehabilitate and purchase

critical equipment only as needed to assist countries to maximize the achievement of their service delivery goals.

The next three chapters describe progress in HSS programming

in low-income countries (Chapter 2), post-conflict countries

(Chapter 3), and more advanced developing countries (Chapter 4).

Chapter 5 presents USAID research and technical collaboration to

develop new tools and approaches for HSS. Chapter 6 summarizes

the funding of USAID HSS efforts worldwide. Chapter 7 summarizes the USAID approach to measuring progress in health systems

assistance. Chapter 8 concludes the report with a summary

description of USAID’s approach, focusing attention on assisting

countries to develop and implement well-managed, targeted and

tracked health systems improvements.

The country examples in this report represent a cross-section of

USAID activities in different settings across all regions. They were

selected to show where and how health systems have been

strengthened in the lowest-income countries, post-conflict countries,

and more advanced developing countries. These country examples

demonstrate how funding accomplishes specific health objectives

and strengthens systems at the same time. Each country example

includes a snapshot of current health statistics, some background

on USAID’s contribution to the long-term development of the

health system, and an illustrative example from the current program.

17
18 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 19

Most of the countries where USAID works are on the lowest

end of the income scale. However, even in countries with low

resources, strained human capital, and weak infrastructure,

USAID has worked to find solutions to health systems problems that result in public health impact. In most low-income

countries, people rely simultaneously on the public, private,

and non-governmental, nonprofit sectors. Out-of-pocket

expenditures for basic health services can overwhelm even

moderately well-off families. And, regardless of the cultural

and political context, across the spectrum of health systems

components, health systems strengthening activities rely on

the commitment of communities if they are to succeed. The

work described in Rwanda, Ethiopia, Kenya, Kyrgyzstan, Haiti,

and Yemen shows USAID’s contributions to the development

of health systems and the impact these contributions have

had on the health of those countries’ citizens. 

When USAID returned to Rwanda after the 1994 genocide,

the Agency, along with other donors, worked closely with the

government to put in place a series of HSS efforts, including

information systems and systems for procuring, storing, and

distributing medicines to reduce stockouts and waste.

Rwanda also is one of the original focus countries of the U.S.

President’s Emergency Plan for AIDS Relief (PEPFAR).

Working in collaboration, USAID and PEPFAR have leveraged

their funds to introduce community-based health insurance. 

USAID also worked with the Government of Rwanda on

reforming health financing, setting policies to rationalize the

workforce, and instituting training for government officials,

managers, and service providers. Recent data suggest these

efforts paralleled a period of improved public health status.

Modern contraceptive prevalence rate more than tripled, from

8.2 percent in 1992 to 28.5 percent in 2007. Between 2005

and 2007, under-5 mortality fell from 192 to 103 per 1,000

live births.

In 2005, Rwanda’s Ministry of Health embarked on a comprehensive decentralization process for the health sector.

There was an immediate need to strengthen capacity for

both local governments and communities to support

improved health service delivery at the local level. USAID’s

Twubakane program – meaning “let’s build together” in

Kinyarwanda – began to improve service delivery and quality

of care, and to improve decentralized governance. Working

with district governments and local administrative units of the

Ministry of Health and Ministry of Finance, USAID provided

technical assistance so that decentralized levels can determine

priority health needs for a specific administrative area and can

manage appropriate interventions. 

In the mid-1990s, USAID collaborated with other donors to

develop the first Health Sector Development Plan, giving the

Ethiopian government a blueprint for HSS. As part of the Plan,

USAID supported activities to strengthen the pharmaceutical

management system, built health centers and sub-centers

linked to local communities, trained health workers, and

developed a robust information management system. At the

end of the decade, USAID helped establish a health sector

financing secretariat in the Ministry of Health to guide policy

decisions on user fees and other finance issues. USAID also

supported a primary health care program, including attention

to health system problems, for the Southern Nations,

Nationalities, and Peoples’ Regional State, one of the four

largest regions in Ethiopia. These HSS efforts paralleled a

2. HEALTH SYSTEMS STRENGT

IN OW NCOME OUNTRIES

HENING

L -I C

RWANDA 

Strengthened

Health Systems

Improves Service

Delivery and

Quality of Care 

Population 10,746,311

Maternal Mortality Ratio per 100,000 live births 750

Under-5 Mortality Rate per 1,000 live births 103

Modern Contraceptive Prevalence Rate (%) 27.4

Income per Capita (PPP international $) 860

HIV Prevalence (%) 2.8

TB Case Detection Rate (% per year) 25

Malaria per 100,000 9,474

Health Expenditure per Capita (US$) 210

Rural Sanitation Coverage (%) 20

Nurses and Midwives per 1,000 0.45 (2005)

Skilled Attendance at Birth (%) 52
20 Sustaining Health Gains – Building Systems

remarkable reduction in under-5 mortality that decreased

from 166 to 123 per 1,000 between 2000 and 2005. Progress

between 2000 and 2005 in family planning programming

showed an increase in modern contraceptive prevalence rate

from 4.7 percent to 9.7 percent, and a 23 percent decrease

in maternal mortality.

The lack of trained medical professionals and community health

workers is particularly acute in Ethiopia, where the latest health

workforce indicators suggest a total of 1,936 physicians for the

entire country, or 0.03 physicians to care for every 10,000

people (WHO, 2006). Under the Ethiopian Public Health

Training Initiative (EPHTI), USAID is assisting five Ethiopian

universities to strengthen the quality of training for health

officers, with a special focus on maternal and newborn health,

high-risk pregnancy, fistula identification and repair, and family

planning and reproductive health practices. PEPFAR funds

support the development of human resources for care and

treatment programs for HIV/AIDS and other HIV/AIDS

interventions. In FY 2008, through additional training and

services, EPHTI reached a critical target of 3,000 health officers

supported by the project and strengthened the capacity of

the five universities by updating technical skills, pedagogical

skills, and managerial capacity. 

USAID has provided broad support to Kenya’s health sector

at each stage in its development over several decades, beginning with efforts to improve basic service delivery in communities and clinics. The program has assisted the Government

of Kenya with health policy development, procurement and

distribution of essential drugs and family planning commodities,

data collection on health indicators, and training of health

care workers. In the face of a declining economy and the

emergence of the AIDS epidemic, USAID expanded its focus

to health care financing, including cost-sharing with the public

sector and supporting a national health insurance scheme.

USAID programs also work to increase health NGOs’ sustainability of, and increase the private sector’s role in, health

service delivery. 

These HSS efforts paralled a period of improved health

conditions. Modern contraceptive prevalence among married

women increased from 10 percent to 32 percent from the

1980s to 1995–97. Measles immunization coverage almost

doubled, from 47 percent in 1989 to 72 percent in 2003, and

TB case detection rate increased from 58 percent in 1996 to

72 percent in 2007. Further, the maternal mortality ratio

declined by 30 percent between 1998 and 2003.

ETHIOPIA 

Addressing 

Gaps in Health

Workers Improves

Family Planning,

Reproductive, and

Child Health Services 

Population 85,237,338

Maternal Mortality Ratio per 100,000 live births 673

Under-5 Mortality Rate per 1,000 live births 123

Modern Contraceptive Prevalence Rate (%) 13.9

Income per Capita (PPP international $) 780

HIV Prevalence (%) 2.1

TB Case Detection Rate (% per year) 28

Malaria per 100,000 730

Health Expenditure per Capita (US$) 22

Rural Sanitation Coverage (%) 8

Nurses and Midwives per 1,000 0.24 (2007)

Skilled Attendance at Birth (%) 6

KENYA

PEPFAR Funding

Builds on More 

than Four Decades

of Support to

Health System

Strengthening and

Addresses Health

Worker Gap

Population 39,002,772

Maternal Mortality Ratio per 100,000 live births 560

Under-5 Mortality Rate per 1,000 live births 115

Modern Contraceptive Prevalence Rate (%) 31.5

Income per Capita (PPP international $) 1,550

HIV Prevalence (%) [7.1 -8.5]

TB Case Detection Rate (% per year) 72

Malaria per 100,000 363 (2002)

Health Expenditure per Capita (US$) 105

Rural Sanitation Coverage (%) 48

Nurses and Midwives per 1,000 1.18 (2002)

Skilled Attendance at Birth (%) 42
Health Systems Report to Congress

In 2006, USAID responded to the critical shortage of trained

health care staff with the PEPFAR-funded Kenya Emergency

Hiring Plan (EHP), a flexible, rapid-response staffing and training

model that deployed large numbers of health workers in less

than half the time of standard public sector recruitment and

deployment practices. The program increased family planning

and child health service access by training and placing workers

in high-need rural areas, including re-opening clinics previously

closed due to staff shortages. Although this private sector

contracting model was originally designed with the government

to quickly deploy 830 HIV workers, the model’s success led

the government to turn to this mechanism regularly. The

program has proved to be sustainable: building on the initial

three-year stop-gap measure, these workers are being formally

transferred to the public service as full-time employees, and

their salaries have been included in government budgets. The

government plans to use the EHP model, which employs

transparent recruiting and hiring, for future rapid hiring needs.

The governments of Tanzania and Malawi recognized the

success of the EHP program and have adopted similar models.

USAID was the first bilateral donor to support the government

of Kyrgyzstan in its National Health Care Reform. With USAID

assistance, the government established the Mandatory Health

Insurance Fund. The Fund’s main objectives were to provide

beneficiaries with medicines and supplies and to trigger reforms

through payment systems that give providers new financial

incentives and autonomy. By 2007, 70 percent of state spending

for health was channeled through the Fund, which insures 80

percent of the population and subsidizes another 8 to 11

percent. USAID now supports the successor to the original

reform. The main goal of the successor reform is the provision

of equal and guaranteed access to high-quality and effective

health services. 

One area where health reform efforts have focused in improving

access, quality, and affordability of services that have an impact

on infant mortality. Assessments showed that although almost

all women were receiving prenatal care and delivering in health

clinics, infant deaths were stagnating at a high level. The problem

was not access, but service quality. The primary strategy was to

improve service quality in an increasing number of facilities and

to inform, encourage, and counsel people to ask for quality

services. Integrated service delivery and improved quality of

care has resulted in reducing the infant mortality rate from 63

deaths per 1,000 live births in 1995 to 27.1 deaths per 1,000

live births in 2008, putting Kyrgyzstan on track to meet

Millennium Development Goal 4 to reduce child mortality. 

USAID’s main HSS activity in Haiti provides development

assistance to the health sector in Haiti through Santé pour le

Développement et la Stabilité d’Haïti – Yon Pwoje Djanm. The

goal is to increase access to and use of the Government of

Haiti’s basic health care packages, and to mobilize partnerships

with the private sector to improve health. USAID supports

the leadership of the Ministry of Health in the decentralization

of health care services, builds strategic management and

targeting of resources for the health sector, and mobilizes

commercial partnerships for improved health. 

Between 2004 and 2007, a period marred by increased

instability and violence, activities focused on the increased use

of quality maternal and child survival services, including immunizations, increased use of quality reproductive health services,

and reduced transmission of selected infectious diseases (TB

and HIV/AIDS) with an increased emphasis on care management and support systems, and integration of behavior change

communication. PEPFAR has also made significant investments

in health systems in Haiti and is working directly with the

government to strengthen the supply chain, information systems

and overall service delivery.

USAID selected 29 target zones in all 10 departments to

reestablish the public sector’s ability to manage the delivery

21

KYRGYZSTAN

Health Care Reform,

Integrated Service 

Delivery, and

Behavior Change

Reduce Infant

Mortality

Population 5,431,747

Maternal Mortality Ratio per 100,000 live births 104

Under-5 Mortality Rate per 1,000 live births 44

Modern Contraceptive Prevalence Rate (%) 45.5

Income per Capita (PPP international $) 1,980

HIV Prevalence (%) 0.1

TB Case Detection Rate (% per year) 60

Malaria per 100,000 9

Health Expenditure per Capita (US$) 127

Rural Sanitation Coverage (%) 93

Nurses and Midwives per 1,000 5.66 (2007)

Skilled Attendance at Birth (%) 97.6
22 Sustaining Health Gains – Building Systems

of basic services, including HIV/AIDS prevention, care, and

treatment services. Central to the program was the belief

that good governance and health are inextricably linked.

Additionally, USAID continued to fund a network of 30 NGOs

to provide health services. The NGOs are held accountable

for results through a performance-based contracting approach.

USAID developed the institutional capacity necessary to

improve the Ministry of Health’s ability to carry out its

executive function at the central and departmental levels for

both public and private providers. The program addressed the

development of realistic, action-oriented policies, cost-effective

implementation of the delivery system, and effective coordination of international community contributions. Specific activities

included engagement of the private sector and engagement

of the Haitian Diaspora, and development of management and

service delivery capacity, including a departmental approach

for improving availability of and access to priority commodities

and a financial management system. 

These improvements paralleled some significant improvements

in health conditions. The rate of childhood immunizations

increased from 21 percent to 63 percent in public sector

target areas. In areas covered by the NGO network, the rate

was 93 percent. The number of deliveries attended by skilled

personnel rose from 17 percent to 26 percent in public sector

areas, and to 68 percent in NGO areas. The use of modern

contraceptives went up to 8 percent from 2 percent in

public sector zones, while in NGO areas, the rate was 32

percent. The number of people tested for HIV increased

from 38,381 to 101,793 in all areas the districts designated

for USAID assistance. 

USAID’s Supply Chain Management Systems (SCMS), a global

program funded by PEPFAR, works with government partners

in Haiti to strengthen systems to manage HIV/AIDS commodities and improve data quality for forecasting and supply planning.

It also provides local technical assistance to improve storage

and distribution practices at treatment and care facilities, and

has established a 1,400-square-meter warehouse in Port-auPrince. It has built local capacity by developing a cadre of

mast trainers to instruct pharmacists, site managers, and

drug dispensers working in treatment centers on techniques

of logistics and stock management. The program’s distribution

network, which started with 12 sites in 2006, now includes

more than 100 sites across the country. As of December

2008, the project had delivered commodities valued at $11.6

million, and health care workers could rest assured that they

will have the continuous supply of medicines needed to enroll

new patients in antiretroviral treatment (ART).

Assistance to Yemen has aimed to improve the health of

women and children by strengthening health service systems.

To build a decentralized workforce able to deliver improved

services, USAID trained hundreds of physicians, midwives,

and female primary health care workers. Programs enhanced

clinical practices in antenatal care, delivery, immunization, and

family planning; strengthened infection prevention and drug

supply; and improved facilities and equipment. Program sustainability was furthered by activities to build community

awareness, capacity, and leadership in managing and supporting

health services.

Health information systems must be robust, describing key

health needs in communities and identifying those needs by

geographic location and socioeconomic status, in order to

inform program and policy decisions. In Yemen, USAID assisted

the government to develop a geographic information system,

called the Health Analyzer, which allows anyone to visually

explore patterns in health indicators. The Health Analyzer

provides a powerful way to identify service gaps – such as

HAITI

Improving Access 

to Services 

and Mobilizing

Partnerships with

the Private Sector 

Population 9,035,536

Maternal Mortality Ratio per 100,000 live births 630

Under-5 Mortality Rate per 1,000 live births 86

Modern Contraceptive Prevalence Rate (%) 24.8

Income per Capita (PPP international $) 1,050

HIV Prevalence (%) 2.2

TB Case Detection Rate (% per year) 49

Malaria per 100,000 115

Health Expenditure per Capita (US$) 96

Rural Sanitation Coverage (%) 12

Nurses and Midwives per 1,000 0.11 (1998)

Skilled Attendance at Birth (%) 26.1
Health Systems Report to Congress

staffing, drugs, equipment, infrastructure, underserved populations, and inaccessibility to health facilities – in order to prioritize

resource allocations.

Governorate and district health officials without access to a

computer have been provided with a health facility atlas that

includes maps of precise geographic locations, photos, and

summary information about health facilities. The success of the

project encouraged the Ministry of Health to scale it up on a

national level. With funding from the World Bank, the health

facilities survey and mapping were conducted for all governorates.

23

YEMEN

Development of

Information Systems

Identifies Critical

Gaps and Needs in

Health Services

Population 22,858,238

Maternal Mortality Ratio per 100,000 live births 430

Under-5 Mortality Rate per 1,000 live births 78

Modern Contraceptive Prevalence Rate (%) 19.2

Income per Capita (PPP international $) 2,200

HIV Prevalence (%) <0.2

TB Case Detection Rate (% per year) 46

Malaria per 100,000 1,264

Health Expenditure per Capita (US$) 82

Rural Sanitation Coverage (%) 30

Nurses and Midwives per 1,000 0.66 (2004)

Skilled Attendance at Birth (%) 36
24 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 25

During conflict, health services are largely delivered by NGOs

and other relief agencies. Once peace is achieved, the responsibility for the health sector transitions to newly established

governments. These governments are under pressure to provide

quality health services to prove their legitimacy. The capacity of

post-conflict governments to provide health services is usually

weak. As the country transitions from relief to development, to

make an impact on health status, the basic elements of a

health system must be built or rebuilt. These include financing,

human resources, and pharmaceutical and commodity provision.

The transition involves finance, leadership, operations, and

ownership. Figure 1 depicts the changing levels of effort needed

in each of these key transitions over time.

Transition of finance refers to helping the country leverage

national revenues and resources to finance health services,

while reducing reliance on uncoordinated relief efforts and

ensuring that coverage gaps do not emerge. Transition of leadership refers to helping post-conflict countries develop national

policy frameworks to guide the health sector. The transition

from relief to development involves setting national standards

for human resources, accrediting health facilities, developing a

basic package of health services, establishing a national health

strategy, and working with decentralized authorities to take on

management and supervision responsibilities.

As the country transitions into peace, it is critical that the

population gain ownership of public services. This area of

work involves empowering civil society to provide oversight

to health facilities, ensuring community-based health and

prevention activities are in place, and working to engage the

populace in policy and resource allocation decisions.

The work described in Southern Sudan, Liberia, and Afghanistan

shows USAID’s contribution to ensuring that basic health

services are delivered to the people of post-conflict settings

under national policy frameworks that legitimize the government, improve health outcomes, and put the country on the

path toward development.

Before the Comprehensive Peace Agreement was signed, the

USAID Office of Foreign Disaster Assistance focused on

providing emergency health, water, and sanitation relief for

the most vulnerable war- and drought-affected communities

in Sudan. Now, USAID is focusing on the development of

core health systems components to ensure that Southern

Sudan has the capacity to deliver high-quality services. USAID

supports efforts to strengthen the capacity of the

Government of Southern Sudan Ministry of Health to

3. HEALTH SYSTEMS STRENGTHENING

IN POST-CONFLICT AND CONFLICT COUNTRIES

Health Systems Strengthening in Post-conflict:

Health Sector Program Emphasis over Time

Figure 1

SOUTHERN

SUDAN 

Increasing Knowledge

of Logistics

Management and

Ensuring Availability

of Critical Medicines

Population 41,088,000 (all Sudan)

Maternal Mortality Ratio per 100,000 live births 2,037

Under-5 Mortality Rate per 1,000 live births 135

Modern Contraceptive Prevalence Rate (%) 6 (all Sudan)

Income per Capita (PPP international $) 1,880 (all Sudan)

HIV Prevalence (%) 1.4 (all Sudan)

TB Case Detection Rate (% per year) 31 (all Sudan)

Malaria per 100,000 8512 (all Sudan)

Health Expenditure per Capita (US$) 61 (all Sudan)

Rural Sanitation Coverage (%) 24 (all Sudan)

Nurses and Midwives per 1,000 0.90 (2006) (all Sudan)

Skilled Attendance at Birth (%) 10
26 Sustaining Health Gains – Building Systems

address public health threats through the development of

policy and information systems, human resources, disease

surveillance, budgeting and finance, and pharmaceutical

management systems. 

USAID’s assistance aims to increase access to, and utilization

of, health, water, and sanitation services to improve the wellbeing of children, mothers, and families. The project funds

local and international NGOs for the continued delivery and

expansion of primary health care services and facilitates health

management capacity building at central and county levels.

When the project identified a lack of comprehensive logistics

knowledge among health personnel as a critical challenge

leading to frequent stockouts and pharmaceutical supply mismanagement, USAID funded training to address these gaps.

Participants from the Ministry of Health, state-level ministries

of health, county health departments, and partner organizations mastered basic health commodity logistics concepts. 

Liberia is emerging from decades of civil war, when much of

the infrastructure was destroyed, and many basic services

collapsed. Today, Liberia is rebuilding its infrastructure and basic

services and focusing significant attention on strengthening

the health system. After the country’s prolonged civil war,

under-5 mortality was cut in half, from 219 deaths per 1,000

births in 1994 to 110 deaths per 1,000 births in 2007.

USAID has implemented a variety of health programs in the

country, and fully engaged in directed health systems strengthening in Liberia beginning in 2004. 

USAID programs have played a major role in drafting a national

health care financing strategy and establishing the groundwork

for further policy development to enhance resource allocation,

examine the impact of user fees, and work with the private

sector. USAID worked with the government to develop

effective routine Health Management Information Systems

and Standard Operating Procedures for essential drugs and

medical supplies. More recently, technical support from USAID

led to establishing Liberia’s first National Health Accounts

analysis (FY 2008 data) and built in-country capacity to

continue this annually through learning tours, training, and

technical support. 

For example, USAID played an instrumental role in the

Liberian Ministry of Health and Social Welfare’s decision to

abandon its policy of favoring only one brand of long-lasting

insecticide-treated nets (LLINs) to prevent malaria. Through

policy dialogue, the Ministry formally abandoned its 2006

policy statement listing only one brand of nets and revised it

in favor of a June 2008 policy that allowed all LLINs that met

WHO standards to be sold and distributed in the country.

This stimulated competition and resulted in lower net prices

for a large USAID procurement under the President’s Malaria

Initiative. USAID continued working with the Liberian National

Malaria Control Program to design and implement a tracking

system for nets, including creating transaction forms for distribution, preparing adequate store rooms, and putting into

place an effective logistics system to transport nets from the

port in Monrovia to communities. 

These programs provided LLINs to 49 percent of the country

and provided 2 million doses of effective malaria drugs. The

2009 draft Malaria Indicator Survey provides evidence of

reduced malaria impact on children. Malaria parasitemia in

children under 5 decreased from 66 percent in 2005 to 32

percent in 2009. Women who received malaria prevention in

pregnancy increased from 4 percent to 45 percent during the

same period. The percentage of children under 5 sleeping

under an insecticide treated net increased from 2.6 percent

in 2005 to 26 percent in 2009. Under the strong leadership

of the Ministry of Health and Social Welfare, and with targeted

policy reform, Liberia has shown what it can do to address

LIBERIA

Developing Systemwide Strategies and

Policies to Protect

More Citizens from

the Spread of Malaria

Population 3,441,790

Maternal Mortality Ratio per 100,000 live births 994

Under-5 Mortality Rate per 1,000 live births 111

Modern Contraceptive Prevalence Rate (%) 10.3

Income per Capita (PPP international $) 280

HIV Prevalence (%) 1.7

TB Case Detection Rate (% per year) 69 (2006)

Malaria per 100,000 23,690 (1998)

Health Expenditure per Capita (US$) 39

Rural Sanitation Coverage (%) 7

Nurses and Midwives per 1,000 0.27 (2008)

Skilled Attendance at Birth (%) 46
Health Systems Report to Congress

infant/child mortality, and has started a steady expansion of

health services from Monrovia and large cities to the periphery.

Afghanistan has some of the worst health indicators in the

world. Since 2002, USAID and other donors have helped the

Afghan government build a health system, beginning with

facilities construction and equipment provision through

development of the National Health Policy and the Health

and Nutrition Chapter of the Afghanistan National

Development Strategy. Improvements have been made in

the health system despite political instability and widespread

insecurity. USAID supported the Ministry of Public Health to

rehabilitate and reinforce key information systems – including

financial management and procurement systems – and to

support health system decentralization and improve the

capacity for management at provincial and local levels.

Thousands of community health workers and community

midwives have been trained. Throughout this period, USAID

and other donors assisted the Ministry of Health to provide

oversight to the nongovernmental agencies delivering the

vast majority of direct services, strengthening the Ministry’s

capacity to manage grants and improve quality of care.

USAID’s current HSS strategy focuses on scaling up direct

service delivery, improving capacity and technical leadership

for health sector governance, and developing the medical

workforce. USAID supported the development of Afghanistan's

Basic Package of Health Services and Essential Package of

Hospital Services. These standards, used throughout the

country, define the minimum expected services, equipment,

and required staff for each level of the health care system in

order to improve and rationalize health care delivery and

facilitate referral systems. USAID continues to provide technical

assistance at all administrative levels to strengthen the implementation and governance of these standards. 

Remarkable improvements have been seen in Afghanistan,

including significant advancements in population health. The

percentage of the population with access to basic health

services went from 9 percent in 2000–2003 to 84 percent

in 2006–2008. During the same period, the percentage of

women in rural areas delivering with a skilled birth attendant

went from 6 percent to 19 percent. Measles immunization

coverage increased from 44 percent in 2002 to 70 percent in

2007, and TB case detection rates increased dramatically, from

4 percent of cases in 1997 to 64 percent of cases in 2007.

27

AFGHANISTAN

Scaling Up 

Service Delivery 

to 84 Percent

Coverage of 

Access to Basic

Health Services

Population 28,395,716

Maternal Mortality Ratio per 100,000 live births 1,600

Under-5 Mortality Rate per 1,000 live births 191

Modern Contraceptive Prevalence Rate (%) 15.5

Income per Capita (PPP international $) not available

HIV Prevalence (%) not available

TB Case Detection Rate (% per year) 64

Malaria per 100,000 1,981

Health Expenditure per Capita (US$) 29

Rural Sanitation Coverage (%) 25

Nurses and Midwives per 1,000 0.5 (2005)

Skilled Attendance at Birth (%) 19
28 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 29

Health systems in more advanced developing countries are

typically able to provide basic preventive, promotive, and

curative care to a large portion of their populations, while

also making progress with quality improvement and equitable

financing. These countries may also be facing a growing burden

of noncommunicable diseases and an aging population.

Nonetheless, these countries continue to face challenges,

especially in terms of equity and sustainability. These countries

often fail to provide adequate health services to the poor,

exacerbating inequities in health and nutrition as well as

dissatisfaction with political institutions. With assistance from

USAID and other donors, these countries are typically

equipped to address problems within each of the health

systems building blocks simultaneously as they move toward

a sufficient level of quality and coverage. As they progress,

both national and local governments are able to evaluate

health systems performance and adjust programs to sustain

improvements in health outcomes, especially those for poor

and underserved populations. 

The work described in Peru, Honduras, Armenia, Egypt,

South Africa, Nicaragua, and Georgia shows USAID’s contribution to the development of these countries’ health systems

and the impact these contributions have had on the health of

their populations. 

In these countries, USAID typically has a smaller health-related

program yet may still be the largest bilateral donor in health.

USAID provides technical assistance that leverages government

and other development partner funding to meet remaining

country and USAID health outcome goals and to reach HSS

benchmarks. Programs tend to focus on stronger governance

and leadership capacity, including partner country capacity to

monitor adherence to health systems performance standards;

improved service delivery, evidenced by adherence to evidencebased quality standards; more efficient and equitable financing

systems; more effective and transparent commodity management systems; better integrated and responsive health management information systems; human resources management

that maintains high professional standards for health providers,

and active involvement of individuals and communities in

successful health care delivery. 

USAID first provided assistance to Peru to improve its health

information and contraceptive logistics systems, which paralleled a doubling of the modern contraceptive prevalence rate

from 23 percent to 46.7 percent over the period 1986–2004.

USAID’s work evolved to address other areas of HSS, including improving the health workforce through training and raising quality of health service delivery, which undoubtedly

played a role in cutting the infant mortality rate by more than

half, from 58 in 1990 to 23 in 2005. Since 2005, USAID has

supported critical dialogue between key health sector actors,

including political parties, to reach a consensus on the need

to advance a health insurance reform and the health decentralization process. USAID has assisted the Ministry of Health

to develop the studies and technical tools to define and cost

the Essential Health Benefit Plan, as well as project the financial

requirement of health insurance reform. USAID has been

instrumental in ensuring that the reforms are progressive and

create access to care for traditionally marginalized populations

– a critical step to securing comprehensive health care for

4. HEALTH SYSTEM STRENGTHENING IN

MORE ADVANCED DEVELOPING COUNTRIES

PERU

Health Financing

Reforms to Ensure

Universal Coverage

for All Peruvians

Population 29,546,963

Maternal Mortality Ratio per 100,000 live births 240

Under-5 Mortality Rate per 1,000 live births 32

Modern Contraceptive Prevalence Rate (%) 46.7

Income per Capita (PPP international $) 7,200

HIV Prevalence (%) 0.5

TB Case Detection Rate (% per year) 93

Malaria per 100,000 284

Health Expenditure per Capita (US$) 300

Rural Sanitation Coverage (%) 36

Nurses and Midwives per 1,000 0.67 (1999)

Skilled Attendance at Birth (%) 70
30 Sustaining Health Gains – Building Systems

the Peruvian population. In 2004, for example, nearly 100

percent of births for women in the richest quintile were

attended by skilled providers, compared to only 65 percent

for women in the poorest quintile.

In March 2009, the Peruvian National Congress approved the

Universal Health Insurance Law. The law includes a mandate

to cover all residents though a gradual and progressive process;

regulation of an Essential Health Benefit Plan specifying covered procedures, financial coverage, quality standards, and

maximum time period for receiving care for all insurers, both

public and private; and creation of a National Supervisory

Institution to oversee the compliance of public and private

providers with health insurance laws and regulations. 

Since 2003, USAID ́s support to Honduras has focused on

strengthening the role of the central Ministry of Health in

terms of regulation and quality assurance of public services

offered to the population. Support also has been provided

to decentralize health care services to improve cost-efficiency,

accountability, and transparency. USAID’s work addresses other

areas of HSS, including defining the national health system,

developing standard models of care, improving pharmaceutical

management systems, and strengthening M&E and health

surveillance systems. The system strengthening efforts facilitate

citizen participation, accountability, and transparency. 

Despite impressive improvements in health outcomes, significant inequities remain. In 2006, an 18 percent gap in infant

mortality, and a gap in the total fertility rate of 3.5, between

the richest and poorest quintiles remained, pointing to ongoing

weaknesses in the health system that could impede the sustainability of past gains. 

Currently, USAID is working with the Ministry of Health to

implement a new program to strengthen health systems and

decentralize health services, particularly family planning and

maternal and child health services. Decentralization occurs

through contracting out services to local-level public or private

providers. Indicators of quality service delivery are developed

and measured, and contracts are then paid against performance.

USAID supports the Ministry of Health to build the indicators

for service delivery contracts, define the norms for contracting

services, and develop the monitoring mechanisms for payment

against performance. USAID also assists public and nongovernmental providers on counseling techniques, essential

obstetric and newborn care and procedures, M&E, and internal

monitoring systems. 

A study conducted in 2009 found that these decentralized

health services reached more citizens, provided better quality,

and were more cost efficient. In those interventions that

show an impact on infant and maternal mortality, decentralized services achieved increases of 27 percent for prenatal

care, 35 percent for attended births, 20 percent for growth

monitoring, and 10 percent for postpartum care as compared

to centralized services covering similar populations.

Since 2000, USAID has played a major role working with its

development partners to assist Armenia in scaling up its

capacity to deliver high-quality, integrated health services and

to strengthen the health systems essential to sustaining this

progress. USAID helped identify key health systems bottlenecks constraining the successful implementation of maternal

and child health, reproductive health and family planning, and

TB initiatives. Addressing these systems weaknesses is contributing to Armenia’s success in reducing maternal and child

morbidity and mortality, decreasing abortion rates, and

improving TB case detection rates.

USAID assistance to introduce health systems interventions

helped institutionalize more equitable and efficient health

financing systems, including offering a Basic Benefits Package

that provides free primary health care and maternity services

for all Armenians; implementing an Open Enrollment System

HONDURAS

Reforms to Health

Governance Bring

Significant Increases

in Coverage 

Population 7,833,696

Maternal Mortality Ratio per 100,000 live births 280

Under-5 Mortality Rate per 1,000 live births 29.6

Modern Contraceptive Prevalence Rate (%) 56.4

Income per Capita (PPP international $) 3,610

HIV Prevalence (%) 0.7

TB Case Detection Rate (% per year) 87

Malaria per 100,000 140

Health Expenditure per Capita (US$) 241

Rural Sanitation Coverage (%) 55

Nurses and Midwives per 1,000 1.32 (2000)

Skilled Attendance at Birth (%) 66.9
Health Systems Report to Congress

whereby every resident of Armenia has a right to choose his

or her own health care provider; improving family doctor and

nurse skills throughout the country; and introducing family

medicine practices. Today, 85 to 90 percent of Armenia’s population of 2.9 million has participated in the open enrollment

program; government spending on primary health care has

increased from 15 percent to 35 percent over the last 10

years; and the primary cause of maternal death in Armenia –

postpartum hemorrhage – has fallen more than 60 percent,

from 5.4 percent in 2005 to 1.7 percent in 2008 in participating facilities. 

Starting in the mid-1990s, USAID worked with the Egyptian

Ministry of Health and Population and other donors to support

Egypt’s Health Sector Reform Program. The objective of the

reform is to develop a national health system with social

insurance to ensure equity in access and financing of health

care, efficiency, quality, and financial sustainability of the health

care system. USAID and other donors continue to support the

country’s rollout in select districts and operational research to

determine the most appropriate primary health care models. 

A significant component of the health reforms was the use of

data. Egypt pioneered the application of the National Health

Accounts framework in the Middle East region in the early

1990s. USAID also supported National Maternal Mortality

Studies and a nationwide maternal mortality surveillance

system. The first study, conducted in 1992–1993, found that

92 percent of all maternal deaths had one or more avoidable

factors, which were widely publicized in Egypt and within the

medical community. The study was conducted again in 2000

after significant work to improve quality of obstetric and

maternity care, increase access to family planning, and educate

women and families about seeking prompt medical attention

during pregnancy and labor. It found that the maternal mortality

ratio dropped 50 percent, from 174 to 84 per 100,000 live

births. To create a sustained, self-sufficient system for measuring

maternal mortality, USAID more recently supported the Ministry

to establish a nationwide surveillance system to identify maternal

mortality at all levels and analyze and discuss contributing factors,

building the capacity of the government to perform subsequent

studies independently.

Approximately 5.7 million South Africans were living with HIV

in 2007, 1.7 million of whom were in need of antiretroviral

therapy to mitigate the effects of the disease. Faced with this

crisis, South Africa’s HIV/AIDS program has rapidly scaled up

treatment efforts with substantial support under PEPFAR. By

March 2009, approximately 750,000 people were on anti31

ARMENIA

Strengthening

Systems Results 

in 60 Percent

Reduction in

Maternal Mortality

from Postpartum

Hemorrhage 

Population 2,967,004

Maternal Mortality Ratio per 100,000 live births 76

Under-5 Mortality Rate per 1,000 live births 29.8

Modern Contraceptive Prevalence Rate (%) 19.5

Income per Capita (PPP international $) 5,870

HIV Prevalence (%) 0.1

TB Case Detection Rate (% per year) 51

Malaria per 100,000 1

Health Expenditure per Capita (US$) 272

Rural Sanitation Coverage (%) 81

Nurses and Midwives per 1,000 4.87 (2007)

Skilled Attendance at Birth (%) 98.4

EGYPT

Maternal Mortality

Falls 50 Percent – the

Latest Result of

Improved Service

Delivery and

Information

Population 78,866,635

Maternal Mortality Ratio per 100,000 live births 130

Under-5 Mortality Rate per 1,000 live births 28.3

Modern Contraceptive Prevalence Rate (%) 57.6

Income per Capita (PPP international $) 5,370

HIV Prevalence (%) <0.1

TB Case Detection Rate (% per year) 72

Malaria per 100,000 <0.01 

Health Expenditure per Capita (US$) 316

Rural Sanitation Coverage (%) 52

Nurses and Midwives per 1,000 3.35 (2005)

Skilled Attendance at Birth (%) 79
32 Sustaining Health Gains – Building Systems

retroviral therapy (ART), and the program was enrolling

30,000 new patients, monthly. Significant challenges remain,

however, among these, maintaining and distributing an adequate drug supply. 

With assistance under PEPFAR, South Africa is strengthening

supply chains for ART with improved resource allocation and

evidence-based management. To combat drug shortages for

AIDS treatment that have occurred in some provinces, the

South African government and USAID partners are modeling

the costs of treatment to improve budget estimates, and the

costs of prevention activities to better inform resource allocation across the program. Local stakeholders’ capacity for evidence-based management is strengthened through training in

M&E and enhanced information systems. Alignment of

HIV/AIDS information systems with South Africa’s own system

improves the ability of local health care managers to better

plan for treatment demand and responds to changes in the

epidemic. Better information for resource allocation and evidence-based management will contribute to a stronger and

more strategic national response to HIV/AIDS overall.

USAID re-established a presence in Nicaragua in 1990 after

the end of the fighting in the 1980s and has provided technical

assistance and support to the Nicaraguan Ministry of Health

since 1994. USAID assisted with the decentralization of health

management functions from the central level to the provincial

offices, making significant progress in the management and

administration of health centers and health posts, as well as

maternal and child health and strengthening institutional

capacity. Between 1990 and 2005, Nicaragua made significant

progress on health indicators. Infant mortality was reduced

from 52 to 30, and total fertility went from 5.2 to 2.7 average

births per woman. By 2006–2007, Nicaragua had achieved

such a high degree of equity in health indicators, specifically

with respect to the contraceptive prevalence rate, that an

analysis found that the population composition was no longer

a relevant predictor of the overall use of contraceptives in

the country. 

Since 2005, USAID/Nicaragua has been working with the

Ministry of Health to improve service delivery through key

institutional reforms. Achievements include developing operational models, technical guidance, and support for a new

health care delivery model that emphasizes delivering primary

care in hard–to-reach areas, and reorganizing the Ministry of

Health, including systems. 

The human resources system was identified as a key bottleneck to health sector sustainability. USAID has worked to

develop all human resources-related procedures and has

SOUTHAFRICA

Improved

Pharmaceutical

Management

Contributes to

Increases in Coverage

of Antiretroviral

Therapy 

Population 49,052,489

Maternal Mortality Ratio per 100,000 live births 400

Under-5 Mortality Rate per 1,000 live births 58

Modern Contraceptive Prevalence Rate (%) 59.8

Income per Capita (PPP international $) 9,450

HIV Prevalence (%) 18.1

TB Case Detection Rate (% per year) 78

Malaria per 100,000 28

Health Expenditure per Capita (US$) 869

Rural Sanitation Coverage (%) 49

Nurses and Midwives per 1,000 4.08 (2004)

Skilled Attendance at Birth (%) 92

NICARAGUA

Decentralization,

Improved Quality,

and Human

Resources Systems

Reform Help

Broaden Service

Coverage

Population 5,891,000

Maternal Mortality Ratio per 100,000 live births 170

Under-5 Mortality Rate per 1,000 live births 35

Modern Contraceptive Prevalence Rate (%) 69.8

Income per Capita (PPP international $) 2,510

HIV Prevalence (%) 0.2

TB Case Detection Rate (% per year) 97

Malaria per 100,000 124

Health Expenditure per Capita (US$) 251

Rural Sanitation Coverage (%) 34

Nurses and Midwives per 1,000 1.07

Skilled Attendance at Birth (%) 74
Health Systems Report to Congress

improved existing health sector human resources through

management and leadership training and the introduction

of methodologies for competency-based on-the-job training.

At the same time, USAID has helped ensure sustainability of

these improvements through the development and introduction of a health administration curriculum for medical students. USAID made significant advances in increasing citizen

participation in health, working with municipal development

committees to organize and broaden citizen participation in

planning, developing guides for social auditing of the health

sector, and creating integrated municipal development plans. 

As political developments reduced the effectiveness of USAID’s

health sector support to national and regional governments,

efforts were successfully adapted to focus more on the local

level. Building on past achievements, USAID shifted its focus

to ensure that local service delivery was linked to, and integrated with, overall health sector improvements. In 2009,

USAID continued to strengthen at national level the logistical

systems for contraceptives and essential drugs, to improve

quality of health services at hospitals and health center levels,

and to increase access to community health services in the

poorest municipalities of the country. USAID developed

instruments to monitor the performance of hospitals and

health units, including a system to track home visit information

and to ensure that performance monitoring served to improve

linkages between primary and secondary levels of care.

Universal access to health care in Georgia is guaranteed by

law. In practice, Georgia’s government has been unable to

provide health care coverage to all its citizens. Hospitals were

overspecialized and deteriorating, and primary health care was

inconsistent when available. In 2004, USAID began devoting

resources to HSS, including health care financing and policy

development, national health accounts, organizational development of the Ministry of Labor, Health, and Social Affairs, and

national reproductive health/family planning policy development.

In 2006, Georgia launched a health reform initiative relying

on market mechanisms to increase the population’s access

to health care, to improve the quality of care, and to increase

the efficiency of service provision. The USAID-supported

reform effort includes widespread privatization of hospitals

and primary health care facilities, a larger role for private

health insurers, and better means testing for state-funded

programs for poor and disadvantaged citizens. Since the

unveiling of the new reform effort, Georgia has endorsed a

hospital privatization master plan, has launched a health

insurance voucher program for the poor and disadvantaged,

has initiated a partly subsidized universal basic health insurance

program, and is planning to privatize primary health care clinics.

By 2009, the government had expanded health care coverage

nationwide to cover additional population groupings, including:

150,000 public school personnel and approximately 900,000

poor beneficiaries. 

USAID assisted the reform effort by helping to institutionalize

the production and use of national health accounts to inform

national decisionmaking; to develop management training programs for hospital and primary health care physicians, as well

as the medical interventions classification system essential for

more transparent health financing systems; to create model

contract agreements between insurers and providers; and to

design professional short training courses in health insurance

and health service management. 

Since the mid-1980s, the Philippines has been at the forefront

among developing countries in its health sector reform efforts,

aiming to expand access and quality of health programs to its

large and widely-disbursed island population. With the assistance

of USAID and other donor partners, the Philippines was

among the earliest developing countries to experiment with

changing management and financing to improve health system

performance. USAID provided support to a succession of

33

GEORGIA

Governance

Reforms Broadens

Provision of Health

Care Coverage

Population 4,616,000

Maternal Mortality Ratio per 100,000 live births 66

Under-5 Mortality Rate per 1,000 live births 35

Modern Contraceptive Prevalence Rate (%) 19.8

Income per Capita (PPP international $) 4,760

HIV Prevalence (%) 0.1

TB Case Detection Rate (% per year) 113

Malaria per 100,000 7

Health Expenditure per Capita (US$) 355

Rural Sanitation Coverage (%) 92

Nurses and Midwives per 1,000 3.89

Skilled Attendance at Birth (%) 98.3
34 Sustaining Health Gains – Building Systems

innovative initiatives in financing for primary health care,

health finance development, health sector reform, and local

empowerment and development. Among the notable

achievements under these initiatives was the Philippines’ capacity

to fully track its own health expenditure data and produce

annually reported National Health Accounts starting in 1995. 

The current USAID health program for the Philippines began

in 2006 in close coordination with the Government of the

Republic of the Philippines’ Health Sector Reform Agenda.

USAID’s approach incorporates all stakeholders in the health

sector, including central and local governments, donors, and

the private sector. It supports local governance strengthening

in health, formation of health policy, improved service delivery,

and behavior change among medical practitioners and their

clients. Programs also build capacity within local governing

units for health management and service delivery, focusing on

management systems, financing, service provision, and advocacy.

USAID supports activities to mobilize the private sector to

increase participation in the health sector. This program

concentrates on promoting family planning and maternal and

child health services through workplace initiatives, market

development, and interventions to expand and strengthen

private practice.

PHILIPPINES

Pioneering Reforms

to Improve

Financing and

Insurance

Population 97,976,603

Maternal Mortality Ratio per 100,000 live births 230

Under-5 Mortality Rate per 1,000 live births 34

Modern Contraceptive Prevalence Rate (%) 34

Income per Capita (PPP international $) 3,710

HIV Prevalence (%) <0.1

TB Case Detection Rate (% per year) 75

Malaria per 100,000 53

Health Expenditure per Capita (US$) 223

Rural Sanitation Coverage (%) 72

Nurses and Midwives per 1,000 6.12 (2002)

Skilled Attendance at Birth (%) 62
Health Systems Report to Congress 35

USAID conducts health systems research and evaluation to

identify, test, and facilitate partner country introduction and

scale-up of best practices that reduce the burden of disease

due to the major causes of mortality and severe morbidity.

USAID health systems research meets four criteria: relevance

to the successful implementation of health interventions in

HIV/AIDS, malaria, tuberculosis, reproductive health and family

planning, maternal and newborn health, and/or nutrition;

potential to improve access, quality and/or affordability; ability

to achieve demonstrable and measurable improvements within

three to five years; and suitability for sustained use in lowresource settings. 

USAID undertakes health systems research and evaluation in

conjunction with WHO, UNICEF, USG agencies and international partners, and partner governments to address countryspecific issues, as well as to resolve cross-country challenges

and to establish the evidence base for the development of

consensus on technical and policy issues. These research

results are immediately made available to the wider public

health community, and some also are submitted to peerreviewed journals for publication.

Through research, USAID Missions help strengthen the

capacity of ministries of health to employ evidence-based

approaches and build the capacity of partner country

researchers to contribute to improved health. 

A listing of illustrative HSS interventions by core function

(building block) is provided in Annex A.

Examples of Widely Used Best Practices

Supported by USAID 

Below are some notable examples of USAID’s legacy of

investment in developing best practices, new tools, and

approaches over the last two decades:

• National Health Accounts (NHAs ) are used by partner

country policymakers to review resource allocation patterns

in the public and private sectors. NHAs provide information

to assess the efficiency of current resource use and provide

options for health care reform. NHAs are now utilized in

more than 100 countries. 

• The Demographic and Health Surveys (DHS) is the gold

standard demographic survey of the population, health,

education, and nutrition of women and children in developing countries. It is used by multiple countries, donors,

and United Nations agencies to track health conditions

and progress in service delivery. 

• Quality Improvement Approaches employed in advanced

industrial countries have been adapted and pioneered by

USAID in developing countries to improve the quality and

reduce the cost of services. 

• Health Financing has been an area of significant USAID focus

to help expand access to quality care through public and

private sector health care providers. Illustrative of this investment has been the development of community-based health

financing schemes that provide savings and financing for

essential health services. In more recent years, USAID has

supported testing of other financing approaches to increase

coverage and quality, such as pay for performance. USAID

has also supported expanding credit to private sector health

providers to improve services and access to health products. 

• Pharmaceutical Management has been a signature area of

USAID investment. Tools and approaches developed with

support from USAID have set the standard for effective,

cost-effective, and prudent use of antibiotics and other

pharmaceutical commodities. Illustrative of this area of

investment are the development of the WHO Global

Strategy for the Containment of Antimicrobial Resistance

and the creation of a drug and therapeutics committee

approach for evidence-based and cost-effective selection

and use of medicines. 

• Health Systems Impact of donor aid programs have been

studied with USAID assistance. This work led to the creation

of the multi-donor-sponsored Global HIV/AIDS Initiatives

Network (GHIN) that links teams in more than 20 countries.

With PEPFAR support, USAID is collaborating with the

U.S. Centers for Disease Control and Prevention in the

design and implementation of public health evaluations of

PEPFAR’s impact on the delivery of other health services

and health systems more broadly. The study is being carried

out in Uganda, Kenya, Nigeria, Mozambique, and Haiti. 

5. BEST PRACTICES IN RESEARCH AND 

INTERNATIONAL TECHNICAL COLLABORATION
36 Sustaining Health Gains – Building Systems

See Annex B for a summary of USAID-sponsored research

and development. 

Applications of New Tools and Approaches

In supporting the identification, testing, and scale-up of innovative approaches to HSS, USAID engages experts from its

health systems resource center projects along with a wide

array of health systems practitioners from throughout the

developing world. USAID’s best practices research supports

new health systems tools and approaches at each stage on a

continuum: from assessment, to development, to introduction,

and on to field implementation. In the remainder of this section,

we present the succession of developmental work for five

illustrative examples of new tools supported by USAID:

1. Improvement collaborative (Service Delivery)

2. Health workforce productivity (Human Resources)

3. Monitoring and evaluation data (Information)

4. Controlling growth of drug resistance (Medical Products,

Vaccines, and Technologies)

5. Health insurance and cost analyses (Financing)

Using Improvement Collaboratives 

to Strengthen Service Delivery

USAID expands the use in developing countries of modern

quality improvement approaches that are common in the U.S.

health system. With adaptation, these approaches have produced promising improvements in health care in a range of

countries and across a number of health services. The most

promising of these approaches is the improvement collaborative approach, pioneered by the Institute for Healthcare

Improvement in Boston, which organizes teams of providers

in a number of facilities to work together to improve the

organization of a specific service. Using their own insights, the

teams test changes in the way they deliver services and share

what they learn with all the other teams. 

The Bolivia TB collaborative, aimed at strengthening the

National TB Control Program’s performance, addressed four

main TB control problem areas: a) increasing detection of respiratory suspects and TB new cases; b) increasing practice of

directly observed treatment, short course (DOTS); c) increasing cure rates and treatment success rates; and d) reducing

abandonment rates.

After developing a tested package of program improvements,

teams of providers participated in an organized effort to

spread improved practices to additional facilities, reaching

217. These facilities achieved important improvements in

rates of TB cures, treatment success, case detection, and

treatment abandonment. 

One of the oldest collaboratives is in Niger, where improved

practices in obstetrical care – covering 32 percent of the

countries maternities – reduced postpartum hemorrhage to

less than 10 percent of baseline levels. These improvements

have been sustained for more than three years, benefiting

more than 100,000 deliveries. These teams have gone on to

improve the care of the newborn, as compared to evidencebased quality standards (Figure 1).

These teams also introduced pre-eclampsia and eclampsia

improvements in 32 facilities as a part of a second phase

(Figure 2).

Gauging and Improving Health Workforce

Satisfaction and Productivity

USAID’s health workforce research aims to improve tools to

measure workforce satisfaction and productivity. A study on

workforce retention in Uganda showed that, contrary to

popular perception, average annual attrition rates are low (1.2

percent) in the public sector, but much higher (13 percent) in

the private, not-for-profit sector. Findings from these studies

showed major causes are leaving assigned posts and retirement,

with the underlying causes being difficult working conditions,

Niger: Improving essential newborn care and 

practice of immediate breastfeeding in EONC

Collaborative sites, January 2006-September 2008

Figure 1
inadequate equipment, poor on-job communications. Rates

varied among different categories of health workers, indicating

the need for different motivation mechanisms for each, which

are now being identified. Based on this experience, USAID is

refining tools for measuring retention and is sharing the

Uganda case study for use in other countries. 

Additional workforce productivity studies were conducted by

USAID in Zanzibar and by the National Institute for Medical

Research in mainland Tanzania to determine productivity levels

and correlates of increased productivity as a basis for global

guidance. An emphasis was placed on implementation at the

facility level. 

Applying findings from these studies, the Ministry of Health

worked with facility stakeholders to select and implement

interventions that are feasible, evidence-based, and inexpensive.

An early assessment indicated increases in job satisfaction and

in worker intentions to remain in these positions. From this

work, USAID is continuing to develop a model for analyzing

workforce satisfaction and productivity that can be used in

other countries, including a package of measures and tools to

improve productivity by identifying and resolving the sources

of worker dissatisfaction and low motivation.

Gender-based inequality and violence in the workplace have a

negative impact on the individual worker and his or her ability

to perform effectively. The frequency with which this occurs is

often not recognized or acted upon due to its socially sensitive

nature. To address this, Rwanda’s Ministries of Labor, Health

and Gender and the Health Workers Union, with support

from USAID, are using findings from a health facility worker

survey to create policies and programs to protect workers

from interpersonal violence and gender discrimination. The

study found that female health workers face negative stereotypes and discrimination in hiring and promotion due to pregnancy and family responsibilities, and that a culture of respect

and gender equality at work lowers the risk of violence. Study

results are being used to advocate for ratification of international labor codes related to maternity protection and protection for workers with family responsibilities. The work in

Rwanda is serving as a model for efforts in other countries.

Introducing New Methods 

for Information Management

USAID develops innovative approaches to information management tools to improve public health, health promotion,

and clinical services. The Monitoring and Evaluation System

Strengthening Tool, developed collaboratively by USAID, the

Global Fund, Office of the U.S. Global AIDS Coordinator,

UNAIDS, WHO, the World Bank, the Health Metrics Network,

and Roll Back Malaria, allows stakeholders to evaluate how

M&E activities are linked and integrated within the national

M&E system and to develop costed action plans to strengthen

the system. The Global Fund mandates use of this tool as

part of its grant negotiation process and has applied it in 70

countries for HIV/AIDS activities, in 53 countries for malaria

activities, and in 57 countries for TB activities. 

To provide the highest-quality data to inform global HIV/AIDS

efforts, USAID's DHS and AIDS Indicator Surveys (AIS) are

important sources for global efforts coordinated by UNAIDS

to estimate HIV/AIDS prevalence among the general population.

USAID partners also have created statistical models to estimate

the HIV prevalence rates of non-household populations such

as inmates, the homeless, and sex workers. 

Understanding and Protecting 

the Effectiveness of Medical Products 

Understanding the community and facility factors that influence

antimicrobial resistance (AMR) is critical to the design and

implementation of appropriate interventions. USAID supported

the development of an AMR module for population-based

surveys that uses the same structure as the other modules of

the DHS and is accessible for country-level use through the

DHS Web site. USAID also supported comprehensive baseline surveys to identify facility-related issues and factors that

impact on AMR (Ethiopia) and assess Accredited Drug

Health Systems Report to Congress 37

Niger: Improving quality of case management for

pre-eclampsia/eclampsia, 31 MOH facilities, 2007

(Baseline) and January-December 2008

Figure 2
38 Sustaining Health Gains – Building Systems

Dispensing Outlet dispensers’ knowledge, practices, and attitudes

relating to AMR and antibiotic use (Tanzania). Information

obtained from these surveys is being used to design evidence-based and locally appropriate AMR advocacy and

containment interventions.

The availability of case and drug management information is

critical to the success of TB programs. An electronic tool that

tracks patient and drug management information, developed

with USAID support, has been adopted for nationwide

implementation in Brazil, and is now being implemented in

the Philippines, Dominican Republic, and Ukraine. In Brazil,

the tool has resulted in an increased rate of case holding,

case detection among contacts, and improved availability of

needed medicines. 

USAID, in collaboration with WHO, supported a multi-country

study on the quality of AMRs in sub-Saharan Africa. The study

results will provide representative information about the proportion of substandard and counterfeit AMRs in Africa and is

expected to result in evidence-based strategies and implementation plans to improve medicines quality.

USAID also established, or strengthened, post-marketing

surveillance systems to sample and test the quality of medicines

in Latin America, Africa, and Southeast Asia. The post-marketing

surveillance data gathered in Southeast Asia were instrumental

in the success of a regional anti-counterfeit operation that led

to the withdrawal of $6.7 million worth of spurious medicines.

Overall, these results have been instrumental in raising local

stakeholder awareness on the need to improve the quality of

medicines in the market. In the Latin American countries, it has

also led to the initiation of regulatory system improvements,

including strengthening registration and national quality control

laboratory capacity.

Improving Evidence and Practice 

in Health Financing

Improvements in health financing in developing countries

depend on better understanding of current financing practices and on better evidence about large-scale approaches

that work. USAID, in collaboration with the Health Research

Unit of the Ghana Health Service, analyzed the impact of

Ghana’s National Health Insurance that covered 6 percent of

the population by the end of 2008. Implementation of the

insurance scheme led to significant improvements in health

care utilization for illness or injury and reduction of out-ofpocket expenditures for care, including the expenditures for

hospitalization. The findings from this study, as well as the

operational challenges associated with scaling up, will be

essential in informing other countries considering social

health insurance. 

Computer-based analytic tools, developed with USAID support,

have improved the availability and quality of data for policymakers in the health sector. The HIV/AIDS Program

Sustainability Analysis Tool (HAPSAT) and the SPECTRUM

suite of models support priority setting and resource allocation

decisions by partner governments planning a national response

to HIV/AIDS. These models use detailed epidemiological,

demographic, and economic data to estimate the financial

and human resources required to sustain and/or scale up a

portfolio of HIV/AIDS programs, and facilitate broad-based

policy dialogue in the formulation of sustainable national

strategies. HAPSAT has been piloted in Zambia and implemented in Cote d’Ivoire, Nigeria, Tanzania, and Ethiopia, with

future introductions of this tool planned in Haiti and Vietnam.

SPECTRUM has been used to facilitate program dialogue in

Rwanda, South Africa, Namibia, Uganda, Botswana, and Nigeria.

It is also used to support UNAIDS’ biannual global projections

of HIV/AIDS impact and resource needs and is currently being

used to assess the implications of proposed WHO revisions

to their HIV/AIDS treatment guidelines. Both models are

routinely updated as new knowledge becomes available.

USAID Technical Collaboration

On an international basis, USAID joins with WHO, the

World Bank, regional development banks, and other agencies

to address health systems problems where discussion and

consensus are needed to remove barriers to progress in

health programs. Through its programs of international

technical collaboration, USAID encourages countries, technical

agencies, and other donors to adopt and use international

standards and best practice guidelines set by WHO and

other relevant bodies. 

USAID is a full participant in two recently formed global

organizations that are focused on two health systems core

functions: information and human resources. The Health

Metrics Network (HMN) addresses the need for health

information and provides support to countries to conduct

assessments and develop strategic plans to facilitate development of systems. USAID provides technical support to the

work of HMN, including development of the HMN consensus

technical framework for country health information systems

(WHO, 2008). The Global Health Workforce Alliance
Health Systems Report to Congress

(GHWA) was created in 2006 as a common platform for

action on human resources for health.

USAID is active in the work of other global health agencies

that support health systems-related investments. These

include the Global Fund, GAVI, and the Reproductive Health

Supplies Coalition. These organizations encourage countries

to address health systems barriers to program success and

have provided funding for some types of health systems

development work. In 2009, the Global Fund and GAVI have

been engaged in a series of joint discussions with the World

Bank for the purpose of harmonizing the three agencies’

funding mechanisms for health systems-related investments.

USAID has been active in consultations with the three agencies during these discussions. USAID is partnering with other

donors, including the Bill and Melinda Gates Foundation,

German Development Bank, and UNFPA to support the

Reproductive Health Supplies Coalition – an unparalleled

“brain trust” for health systems research and innovation. The

innovative collaboration of PEPFAR, USAID, and the WHO

led to the development of a global approach to task shifting

(see Annex C). 

39
40 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 41

The WHO defines a health system as “all organizations, people,

and actions whose primary intent is to promote, restore, or

maintain health” (WHO 2007). In order to achieve this intent,

health systems rely on a myriad of cross-cutting activities. For

the purpose of clearly articulating and tracking an interlocking

web of activities that define the goal of the health system, the

WHO framework for HSS defines six core functions of a

working health system: human resources; medical products,

vaccines, and other technologies; financing; information; leadership

and governance; and service delivery. These core functions are

the basic, internationally understood areas that are used to

judge and evaluate health systems. Their aggregate encompasses almost all non-research and administration activities

funded by USAID. 

The U.S. Department of State/USAID Foreign Assistance

Framework tracks activities and funding according to an

established set of disease-specific and health program-specific

elements that capture and operationalize congressional appropriation sub-accounts and directives. The framework provides

detailed information on programs and funding for the health

elements – maternal and child health (MCH), malaria, tuberculosis, family planning and reproductive health, avian influenza,

water supply and sanitation, HIV/AIDS, and other public health

threats. Within each of the Elements, sub-elements track more

specific activities that contribute to the element. The subelements of the MCH element, for example, involve issues in

maternal and child morbidity and mortality such as treatment

of child illness, birth preparedness and maternity services, and

newborn care and treatment.

Because USAID takes a development approach to all health

programming, much of what is done in the health sector is

designed to develop and strengthen local institutions and capabilities. The Foreign Assistance Framework used by USAID to

track funds, however, was not set up to track cross-cutting

health systems activities, although it is possible to categorize

some health sector assistance as part of the six functions, or

building blocks popularized by WHO. 

Three of the six health system functions – governance, finance,

and information – are captured under each element as subelements of the framework. Funding for anti-microbial resistance-related programming (which focuses on setting pharmaceutical useage standards and changing behaviors by provider

and patients), pharmaceutical management, and medical

supplies can be calculated using other tracking tools. For the

purpose of this report, the remaining activities under each

element are classified separately as “service delivery including

human resources,” as the activities consist largely of sub-elements

that fall in these functions. In the case of MCH, for example,

the service delivery activities include immunization; newborn

care and treatment; birth preparedness and maternity services;

treatment of obstetric complications and disabilities; polio;

nutrition; treatment of child illness; and household water, hygiene,

and sanitation. Next year, under USAID’s new health systems

strategy, the Agency will be able directly to track funding for

HSS activities under service delivery and human resources. 

Based on an analysis of funding attributed to the Elements of

the Foreign Assistance Framework, USAID has identified a total

of $821,952,512 of $1,728,144,477 appropriated in FY 2008

(see Table 1) that can be classified in one of the six health systems functions. This amount includes funding from all accounts

for all elements except HIV/AIDS and avian and pandemic

influenza. (HIV/AIDS funding is analyzed separately, below, and

Avian and Pandemic Influenza funding is emergency funding

meant for the immediate response to the pandemic.) In addition, another $906,191,965 is classified as service delivery and

human resources (see Table 2). At this time, USAID cannot

identify specific health systems activities for these funds, but this

will become possible as specific health systems indicators and

tracking tools are developed. 

It should be noted that the funding represented in the charts is

not in addition to the funds appropriated for health or diseasespecific areas, but rather another way of representing this same

funding in terms of the functions of the health system.

HIV/AIDS

As of the end of fiscal year (FY) 2008, USAID had implemented

approximately 57 percent of the interagency U.S. President’s

Emergency Plan for AIDS Relief (PEPFAR) bilateral funding. In

FY 2009, total bilateral enacted funds for PEPFAR amounted

to $5,462 billion, to date, approximately $2.4 billion implemented

by USAID. At USAID, HIV/AIDS programs engage in strengthening health systems through:

6. FUNDING FOR HEALTH SYSTEMS STRENGTHENING
42 Sustaining Health Gains – Building Systems

Table 2. Service Delivery/Human Resources Functions Within Each Health Element*

(The current framework cannot track the proportion of these funds that related directly to HSS activities.)

Total FY08 Service Delivery/Human Resources Planned Funding

Tuberculosis $79,960,819

Malaria $123,312,981

Maternal and Child Health $460,664,970

Other Public Health Threats $30,413,064

Family Planning/Reproductive Health $211,839,861

Total $906,191,965

Note: Tables do not include funding for HIV/AIDS or Avian Influenza.

Table 3. TUBERCULOSIS

Health Systems Functions Total FY08 

Planned Funding

AMR/Pharmaceutical

Management/Medical Supplies $48,642,423

Information $8,240,950

Governance/Finance/Policy $3,707,356

Other (health system-related activities) $20,723,670

Total $81,314,399

Table 4. MALARIA

Health Systems Functions Total FY08 

Planned Funding

AMR/Pharmaceutical

Management/Medical Supplies $164,153,551

Information $21,730,774

Governance/Finance/Policy $50,467,580

Other (health system-related activities) $35,591,253

Total $271,943,158

Table 6. OTHER PUBLIC HEALTH THREATS

Total FY08 Health Systems Functions Planned Funding

AMR/Pharmaceutical $0 Management/Medical Supplies

Information $557,161

Governance/Finance/Policy $60,927,392

Other (health system-related activities) $4,308,409

Total $65,792,962

Table 1. Health Systems-related Funding 

(all accounts except HIV/AIDS and Avian Influenza)

Cross-cutting Health System Functions within All Health Elements

Health Systems Functions Total FY08 

Planned Funding

AMR/Pharmaceutical

Management/Medical Supplies $336,970,287

Information $115,730,519

Governance/Finance/Policy $220,267,753

Other (health system-related 

activities) $148,983,507

Total $821,952,512

Separate Health Elements 

(Tables 3 to 7 add up to the totals in Table 1, above)

Table 5. MATERNAL AND CHILD HEALTH

Total FY08 Health Systems Functions Planned Funding

AMR/Pharmaceutical $72,575,029 Management/Medical Supplies

Information $32,508,664

Governance/Finance/Policy $50,467,580

Other (health system-related activities) $38,151,488

Total $193,702,761
Health Systems Report to Congress

• focused investments necessary to achieve HIV/AIDS prevention, care, and treatment goals;

• investments in activities with additional non-disease-specific

impacts that benefit to the overall health system; and

• targeted leveraging with other donors or U.S. Government

(USG) partners.

Based on a separate analysis, OGAC has determined the following investments in HSS for FY 2009 in 31 countries where

PEPFAR money is implemented by all USG agencies. Drawing

on Country Operational Plans, the analysis below reflects

funding for HSS across all PEPFAR implementing agencies in

the Elements listed, totaling $922 million. The $922 million

reflects an initial estimate calculated in February 2009. OGAC

anticipates HSS investments to increase in FY 2009 once all

resources have been programmed in the Country Operational

Plans (COPs). Plans for data collection in the future should

allow for Agency attribution. 

• Logistics and commodities support: $228.5 million

• Strategic information: $138.2 million

• Human capacity development: $379.9 million

• Program activities attributable to other HSS: $175.7 million

PEPFAR also invested in infrastructure and construction in FY

2009 (see box, right).

43

Table 7. FAMILY PLANNING AND REPRODUCTIVE HEALTH

Health Systems Functions Total FY08 

Planned Funding

AMR/Pharmaceutical

Management/Medical Supplies $51,600,000

Information $52,692,970

Governance/Finance/Policy $99,747,925

Other (health system-related activities) $49,848,687

Total $253,889,572

Below is an estimate of PEPFAR investments in 

construction and rehabilitation, especially laboratory

infrastructure, across all USG agencies, totaling

$201,300,000 (see Table 2, below). OGAC anticipates

FY 2009 investments to increase once all resources

have been programmed in the Country Operational

Plans (COPs).

TABLE 1: USAID CONSTRUCTION AND REHABILITATION 

IN HEALTH FUNDING BY PROGRAM LOCATION AND REGION 

(USD FY 2008)

Location Region Total

Africa $26,234,924

Asia $16,918,560

Field

Mission

Europe & Eurasia $4,729,648

Latin American

and the Caribbean $8,823,986

Middle East $59,075,192

Field Mission Subtotal $115,782,310

Centrally-Managed Field Programs $2,041,000

GRAND TOTAL $117,823,310

TABLE 2: PEPFAR INVESTMENTS IN 

CONSTRUCTION AND REHABILITATION 

(USD FY 2009)

Category Total

Laboratory Infrastructure $172,600,000

USG-managed Construction

Projects $28,700,000

GRAND TOTAL $201,300,000

Construction and Rehabilitation

USAID assistance can include construction and rehabilitation of health facilities where needed and where

support is not available from other donors. A total of

$117,823,310 in construction and rehabilitation was

provided during FY 2008 from all sources and appropriation accounts, except for the PEPFAR program (see

Table 1, below). Of significance, a large portion of the

spending in the Middle East region is supporting the

construction of essential health facilities.
44 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 45

Given the complexity of HSS interventions and the need to

tailor interventions based on country situation, the global

community has yet to reach a consensus on internationally

approved indicators and benchmarks to measure HSS. The

lack of consensus surrounding a limited set of tested and

accepted indicators related to health systems hinders efforts

to track progress. Many valid indicators exist for tracking

health systems, but there is no standard set of indicators

collected by one or more countries that could facilitate the

analysis necessary to demonstrate evidence-based results of

investments in health systems. USAID currently collaborates

with the Health Metrics Network, WHO, and other research

centers in the United States and overseas devoted to the

development of better consensus health systems indicators

and progress measurement tools. 

USAID and its partner organizations have developed a variety

of methods for measuring the individual areas of HSS. At the

global level, USAID has contributed the following tools to

monitor and benchmark HSS interventions:

• The Health Systems Assessment Approach is a key prioritysetting tool that guides a rapid yet comprehensive review

of the health system’s six functions. Health System

Assessments have been conducted to inform the development of National Health Strategies, Health Sector Reviews,

and USAID Field Missions Strategic Planning and Program

Design (e.g., Benin, Angola, Nigeria, Vietnam, Pakistan,

Southern Sudan, and Namibia)

• The Health Systems Database compiles key health systems

indicators from existing online data sources (e.g., DHS,

WHO Statistical Information System, and World Bank

World Development Indicators) to produce data-driven

health system profiles and analytical tools

• Health Systems Dashboards are a notable feature of the

Health System Database and facilitate benchmarking country

health systems against their regional and income-group

peers. These visual representations of health systems

indicators guide users to key areas of the health systems

building blocks that should be further analyzed. 

USAID has also developed tools to monitor and benchmark

HSS at the regional level. For example, in Latin America and

the Caribbean:

• The Guidelines to Assess the Steering Role Function of

National Health Authorities assists countries in the Americas

to conduct a self assessment of their capacity to provide

adequate stewardship and oversight of public and private

health sectors in order to identify areas to strengthen

and improve.

• The Health Sector Analysis Methodology outlines the country’s

health situation as well as the performance of the health

system. The Analysis also orients the identification and

selection of priority interventions for health policy formulation and health systems development. The Health Sector

Analysis process results in the identification of policies

and/or plans, programs, projects and interventions oriented

to maximize the impact of the sector in reaching national

health objectives and/or priorities.

• Health Systems and Services Profiles have been completed

and updated in three rounds in the Americas. They provide

a succinct and analytical description of the structure and

dynamics of each country’s health system.

As USAID continues to work with other development

partners and country stakeholders to expand on existing

tools and approaches and contribute to addressing the major

challenges to measuring HSS actions, it will address the following considerations:

The USAID approach makes strengthening health systems a

deliberate and measurable aspect of all health programs. Tools

are being developed to begin tracking progress in each of the

six health functions, as well as the implementation costs. This

approach will help USAID monitor its investments in HSS

7. MEASURING PROGRESS IN HEALTH SYSTEMS STRENGTHENING
46 Sustaining Health Gains – Building Systems

and draw data-based conclusions about their contribution to

improving access, coverage, quality, and efficiency.

At the country level, USAID will continue support to strengthening national health information systems, institutionalizing key

health systems data processes (e.g., resource tracking using

National Health Accounts and Subaccounts), streamlining

surveys and other data collection tools, and strengthening

country capacity for management and use of data. At the

global level, USAID will continue to work with other development partners and global stakeholders to build the empirical

evidence on health systems indicators, to set targets and

thresholds useful for programming purposes, and to participate in discussions and processes on refining the concepts

and measurement tools around health systems performance.
Health Systems Report to Congress 47

The long-term sustainability of partner country programs that

address child, maternal and reproductive health; that control

major diseases,2 and that reduce abortion will depend in

large measure on the capacity of partner country public and

private health systems to produce high quality, accessible, and

efficient services. The challenge for USAID and the partner

countries with which it works is to identify and strengthen

those parts of health systems whose strengthening is most

critical in the local context to addressing the major local

drivers of human health, collaborating with partner country,

private sector, and other donors to reach a minimum standard across each core function. 

While many kinds of activities can contribute to strengthening

health systems, USAID uses a strategic approach that is based

on extensive evidence and experience to target the most

critical health systems function needs and elements. USAID

helps countries move toward sustainability through continued

integration of disease-specific interventions and information

to promote health and prevent disease into the broader

health system – increasing efficiency while protecting progress

on disease-specific interventions. 

USAID helps countries build functionality in six core areas:

service delivery; financing; leadership and governance; human

resources; information systems; and medical products, vaccines, and technologies. In countries that are more advanced

in integration and basic functionality, USAID more comprehensively addresses often substantial barriers to equity and

sustainability. Helping countries enhance the effectiveness of

the health workforce is pivotal to making progress in all of

these areas.

USAID’s programs will continue to emphasize quality

improvement in health care delivery, with special attention on

providing highly cost-effective health promotion and disease

prevention information and services, eliminating waste and

inefficiency, strengthening strategic planning and management

systems, strengthening monitoring and evaluation (M&E)

systems, and developing partner-country capacities. USAID

programs will continue to develop the tools and approaches

necessary to strengthen and expand the health workforce

and to sustain these improvements. They will improve the

capacity of partner countries to provide information, services,

essential drugs, and other health commodities in the communities where people live, and assist countries to develop and

apply improved health financing strategies that mobilize adequate funds for health services, pool resources to spread

costs, and efficiently allocate resources for equity and optimal

health impact. 

2. Especially HIV/AIDS, malaria, tuberculosis, and neglected tropical diseases.

8. CONCLUSION: THE USAID APPROACH 

TO HEALTH SYSTEMS STRENGTHENING
48 Sustaining Health Gains – Building Systems
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Health Accounts with Special Applications for Low-Income

and Middle-Income Countries. Geneva: World Health

Organization, 2003.

REFERENCES
50 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 51

Population The midyear population estimate for July 1 of

the given year.

Source: U.S. Census Bureau International Database 2009

Maternal mortality ratio The estimated number of

women who die as a result of pregnancy or childbirth per

100,000 live births.

Source: Demographic Health Surveys (2003–08), except for

Afghanistan (Bartlett 2002); Albania, Georgia, Kazakhstan,

Kyrgyzstan (MICS 2005–06); Nicaragua, Southern Sudan

(WHO 2005)

Under-5 mortality rate Annual number of deaths that

occur in children 0–4 years old per 1,000 births (five-year

period preceding survey). 

Source: Demographic Health Surveys (2003–08), except for

Afghanistan (Afghanistan Health Survey [AHS] 2006); Albania,

Georgia, Kazakhstan, Kyrgyzstan (MICS 2005–06); Southern

Sudan (Sudan Household Health Survey [SHHS] 2007);

Nicaragua (RHS 2006)

Modern contraceptive prevalence rate Percent of

currently married women ages 15–49 currently using a modern

method of contraception. Modern methods include oral

contraceptives, IUDs, injectables, female and male sterilization,

all emergency contraception, and barrier methods

(diaphragm, foam, jelly, male and female condom). 

Source: Demographic Health Surveys (2003–08), except for

Afghanistan (AHS 2006); Albania, Georgia, Kazakhstan,

Kyrgyzstan (MICS 2005–06); Southern Sudan (Population

Reference Bureau 2009); Nicaragua (RHS 2006)

Income per capita The gross national income per capita

(PPP international $) comprises the total value of currently

produced final goods and services produced by the domestic

economy of a country measured within a given period of

time, usually a year, and divided by its midyear population.

Source: WDI 2009, Data are for 2007

HIV prevalence Estimated number of adults and children

living with HIV. Adults are 15 years and over. Children are

defined as those ages 0–14 years. 

Source: UNAIDS 2007

TB case detection rate The percentage of the annual

new smear-positive notifications of the estimated annual new

smear-positive incidence.

Source: WHO Global TB Database 2009. Data are for 2007

Malaria cases per 100,000 Number of malaria cases

per 100,000 of the population during the year for which data

were reported. 

Source: WHO Roll Back Malaria Database 2003

Health expenditure per capita The sum of public

and private health expenditures figured as a percentage of a

country's gross domestic product. It covers the provision of

health services (preventive and curative), family planning

activities, nutrition activities, and emergency aid designated for

health, but does not include provision of water and sanitation.

Source: WHOSIS 2009. Data are for 2006

Rural sanitation coverage (%) Percentage of the

rural population with access to improved sanitation facilities.

Refers to facilities that ensure hygienic separation of human

excreta from human contact, including: flush or pour-flush

toilet/latrine to piped sewer system, septic tank, or pit latrine;

ventilated improved pit latrine; pit latrine with slab; and

composting toilet. 

Source: UNICEF, WHO 2008 Joint Monitoring Programme for

Water Supply and Sanitation Report

Nurses/midwives per 1,000 population The number

of nurses and midwives per 1,000 population.

Source: WHO Global Health Atlas 2009. Data are for various

years:. Haiti (1998); Peru (1999); Honduras (2000); Kenya,

Philippines (2002); Nicaragua (2003); Nepal, South Africa

(2004); Egypt, Rwanda (2005); Tanzania (2006); Albania,

Armenia, Ethiopia, Georgia, Kazakhstan, Kyrgyzstan (2007);

Ghana, Liberia, Niger (2008)

Skilled attendance at birth Percentage of births

attended by a doctor, nurse, or trained midwife

Source: Demographic Health Surveys (2003–2008), except for

Afghanistan (AHS 2006); Albania, Georgia, Kazakhstan,

Kyrgyzstan (MICS 2005–06); Southern Sudan (SHHS 2007);

Nicaragua (RHS 2006)

SOURCES FOR COUNTRY STATISTICAL SUMMARIES
52 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 53

USAID assists countries to strengthen health systems with targeted, cost-effective interventions to improve policies and

management of one or more core functions (building blocks), below, whether to create a sustainable process in-country

or to build local capacity, or both. 

ANNEX A. ILLUSTRATIVE HEALTH SYSTEMS INTERVENTIONS

Core Functions Illustrative Priority Health Systems Strengthening Interventions

Human

Resources (HR)

•

•

•

To improve workforce policy and planning:

– Strengthening HR information systems 

– Supporting development/implementation of evidence-based HR strategies 

– Testing and expansion of workforce planning and management innovations

– Training HR managers/developing a cadre of professional HR managers

– Strengthening HR units within ministries of health/organizations 

– Implementing innovative worker contracting mechanisms

– Modeling rational distribution of HR for health

– Advocacy for policies that will increase workforce retention and productivity

To better prepare the workforce:

– Strengthening pre- and in-service curricula, faculty/trainers, and methodologies

– Developing/implementing continuous professional development programs, such as through professional associations 

– Training workers in critical gap areas (technical/clinical, logistics, pharmaceuticals, commodities, etc.)

– Integrating a competency approach to counseling and interpersonal communication into health workers’ 

best practices

To support worker performance on the job:

– Implementing work climate improvement programs

– Implementing worker retention schemes

– Planning and implementing task shifting programs

– Establishing norms of service for health workers

– Strengthening supportive supervision systems

Financing

•

•

•

•

To improve mobilization:

– Expanding private sector credit

– Improving transparency and accountability for donor funds

To improve pooling:

– Assessing available risk groupings for use in scaling up insurance

– Building management ability and actuarial soundness of community-based health insurance mechanisms

– Preparing information systems and HR to support movement toward national health insurance 

To improve allocation:

– Analyzing options for optimizing targeted subsidies

– Planning and implementing performance-based financing

– Developing and analyzing cost-based models of service production options

– Building skills of managers to develop and manage contracts 

– Upgrading systems for financial management

– Opening investments in private provision and franchising 

– Creating incentives for evidence-based decisionmaking 

To improve knowledge base:

– Creating networks of National Health Accounts country teams

– Facilitating community participation in insurance enrollment; adoption of equity as a norm; and advocacy 

for adequate financing
54 Sustaining Health Gains – Building Systems

Core Functions Illustrative Priority Health Systems Strengthening Interventions

Medical

Products,

Vaccines, 

and Other

Technologies

•

•

•

•

To promote pharmaceutical sector governance: 

– Developing policies, systems, and procedures to promote transparency and accountability and reduce 

vulnerability to corruption

– Strengthening regulatory capacity to ensure the quality, safety, and efficacy of medicines 

– Increasing participation of civil society for pharmaceutical policy advocacy

– Developing norms and standards, such as pharmaceutical management standard operating procedures, to

improve delivery of pharmaceutical services

– Developing public standards and pharmacopeial monographs for procurement and for the analysis of medicine quality

To improve availability of quality medical products: 

– Procuring a wide range of pharmaceuticals for USG-supported health programs

– Providing technical assistance to strengthen procurement practices and supplier performance monitoring

– Providing technical assistance for the design and operation of reliable, efficient, and effective pharmaceutical

management systems/supply chains 

– Promoting integration across the supply chain and strengthening country capacity (including procurement

processes, forecasting/quantification, supply planning, storage and distribution, etc.)

– Developing and implementing commodity security strategies at different levels

– Strengthening national quality control laboratories and pharmacovigilance systems, including post-market

surveillance of the quality of medicines

– Providing technical assistance to improve current compliance of Good Manufacturing Practices among 

manufacturers producing USAID-priority medicines

– Developing strategies for the introduction and integration/dissemination of new medical products and 

technologies into existing systems

To improve access to essential pharmaceutical services: 

– Increasing use of the private/NGO/faith-based organization sectors to increase access to medicines in 

underserved areas, including the use of innovative financing schemes

– Establishing and sustaining accreditation or certification approaches to improve the quality of products 

and services provided by local drug distribution outlets

To promote the rational use of medicines:

– Providing technical assistance and training to develop human resource capacity to improve prescribing 

and dispensing practices

– Promoting adherence approaches that ensure treatment effectiveness

– Supporting curriculum reform in public health educational institutions to include rational use and antimicrobial

resistance (AMR) issues

– Developing AMR advocacy and containment programs, including institutional interventions (e.g., drug 

and therapeutics committees, infection control); coalition building; and communication/educational campaigns

Information

•

•

•

•

•

•

To enhance country capacity: 

– Supporting organizational development, management leadership, and individual capacity to produce, analyze,

disseminate, and use strategic health information, from national level to community level

To mobilize and coordinate resources:

– Facilitating country-led, multi-stakeholder assessment of current Information system components and processes

to inform near- and long-term coordinated strengthening strategies and costed action plans

To harmonize indicators:

– Developing global standards for, and providing assistance in, country application of key indictors and M&E guidelines

To generate reliable and timely data sources:

– Strengthening country processes and systems, including routine health information systems, integrated disease

surveillance and response systems, nationally representative censuses and household and facility surveys, and

program M&E

To strengthen data management and quality:

– Developing and supporting implementation of tools to identify weaknesses and plan for priority strengthening actions

To facilitate data dissemination and use:

– Facilitating the translation of data into user-friendly information and document its use for evidence-based 

management decisionmaking, planning, advocacy, and policy development

– Building community participation in evidence-based decisionmaking for health and in advocacy for improved

response to disease surveillance and crises
Health Systems Report to Congress 55

Core Functions Illustrative Priority Health Systems Strengthening Interventions

Leadership 

and Governance

•

•

•

•

•

To rationalize ministry of health stewardship role:

– Strengthening leadership, management capacity, and systems

– Strengthening systems for decentralized health sector management

– Assisting ministries of health to strengthen capacity and systems for coordinating NGO, donor, and private

sector engagement. 

– Conducting policy dialogue based on evidence

To empower civil society: 

– Benchmarking health system performance

– Strengthening national and global networks 

– Building advocacy capacity

– Monitoring impact of global initiatives

To empower private sector:

– Facilitating enabling legal and regulatory environment

– Carrying out private sector assessments

– Establishing public-private partnerships and dialogue

– Strengthening government stewardship for oversight of the private sector

To strengthen leadership and management: 

– Providing leadership and management training

To build knowledge base:

– Carrying out national health system assessments

– Applying health governance conceptual framework 

– Increasing community coalition building

– Packaging and disseminating information to increase transparency

Service

Delivery

•

•

To improve access to and quality of services:

– Developing evidence-based, integrated packages of services and guidelines

– Testing innovative training strategies

– Introducing modern quality improvement methodologies and the improvement collaborative

– Structuring public-private partnerships for improved quality and access

– Linking community-based and facility-based services to reach target audiences 

– Rationalizing the pattern of patient referrals

– Improving interpersonal communication skills of health care providers

– Ensuring availability of supplies and commodities at service delivery points

To involve communities and individuals in healthy behaviors:

– Establishing and sustaining social marketing of health-related products or services

•

– Establishing and sustaining community behavior change communication

– Empowering health consumers in social mobilization for infrastructure development and maintenance

– Introducing spousal communication services to address gender equity 

– Increasing the quality and quantity of health reporting in the media

– Linking health information and services with local cross-sectoral programs

To gather and use data to improve health services:

– Establishing participatory monitoring of services and increased prevention efforts

– Supporting knowledge management for health care improvement
56 Sustaining Health Gains – Building Systems
Health Systems Report to Congress 57

Human Resources

• Human Resources for Health (HRH) Action Framework.

First published in the 2006 World Health Report, this

Web-based framework and tools provide a comprehensive

approach to addressing HRH challenges at the country

level. The result of collaboration among multilateral and

bilateral agencies, donors, partner countries, NGOs, and

the academic community, it has now been applied in at

least four countries with support from USAID and the

Global Health Workforce Alliance (GHWA). It also served

as the basis for GHWA’s Kampala Global Forum on HRH,

held in March 2008. 

• Human Resource Information Systems. This suite of three

databases to 1) track worker training, certification, and

licensure; 2) manage and deploy personnel; and 3) provide

long-term workforce modeling and planning, has been

designed using free and open source software to avoid

licensing and other long-term expense and maintenance

issues. The databases are being implemented in eight

countries to date, supported by a constellation of activities,

including forming participatory stakeholder leadership

groups and training in data-driven decisionmaking for

strengthening the health workforce.

Medical Products, Vaccines, and Technologies

• Global Health (GH) Toolkit. GH tools and approaches

continue to dramatically improve supply chain management

and the availability of contraceptives and essential medicines,

thereby reducing stockouts and assuring continuing contraception and effective treatment for HIV/AIDS, malaria, TB,

and MCH programs worldwide. 

• WHO Global Strategy for the Containment of Antimicrobial

Resistance. USAID provided technical and financial support

to develop this landmark WHO document, which provides

a comprehensive set of evidence-based, consensus recommendations for AMR containment. USAID has also supported the development of successful country-specific

AMR intervention packages based on the strategy, involving

health providers, patients, education reform, the media,

governments, and health systems. 

• Quality Assurance (QA) of Medicines. GH continuing advocacy

regarding the critical importance of medicines quality has

moved USG regional and country programs and other

international initiatives to focus specifically on QA system

issues. For example, USAID-supported post-marketing

surveillance data and training were instrumental in facilitating

the successful Interpol-led “Operation Storm” in the

Greater Mekong Region. About $6.7 million of counterfeit

medicines were confiscated in Cambodia, China, Laos,

Thailand, Indonesia, Vietnam, and Singapore. Government

actions also led to the banning of selected products,

manufacturers, and distributors. 

• Drug and Therapeutics Committees (DTCs). USAID-supported

training and follow-up programs have capacitated hospitals

to implement evidence-based and cost-effective selection

and use of medicines. Nineteen courses have trained 861

participants from 71 countries, resulting in the establishment

or restructuring of more than 92 DTCs worldwide and

implementation of hundreds of DTC-related interventions. 

• Improving Supply Systems. An innovative collaboration

between USAID and the U.K. Department for

International Development led to the design and nationwide rollout of a new distribution system for condoms and

contraceptives in Zimbabwe. The system adapts commercial sector best practices and has dramatically improved

product availability at service facilities. HIV commodities

have since been added to the system with similar results,

and USAID is now conducting research to add more

health supplies. 

• Mobilizing Resources. USAID technical assistance supported

a Global Fund decision to fund more than $2.4 million for

contraceptives in Rwanda for 2008–10. For Rwanda, and

globally, this was the first-ever such decision, and a major

breakthrough for leveraging new funding sources for contraceptives.

Information 

• USAID’s Demographic and Health Survey (DHS). For the

past 25 years, DHS has been the gold standard in household

ANNEX B. SUMMARY OF USAID-SPONSORED

HEALTH SYSTEMS RESEARCH AND DEVELOPMENT
58 Sustaining Health Gains – Building Systems

survey methodology, innovating in data collection, analysis,

and dissemination, including the use of biomarkers, the

application of geographic information systems, and offering

of the Web-based STATcompiler for access to datasets. 

• Global Standards for Health Information Systems and M&E.

USAID has provided leadership for HMN, Routine Health

Information Network (RHINO), and toolset for

Performance of Routine Information System Management

(PRISM), as well as technical leadership in M&E of health,

population, and nutrition programs, including M&E manuals

and indicator guides.

• Support of the “Third One.” USAID has also provided

technical leadership and collaborative/coordinated efforts

in support of the “Third One” to strengthen country

capacity and HR in M&E for effective and efficient use of

resources and results-based management.

Financing

• Performance-based Financing (PBF). USAID experience

contributed to Norway’s decision to grant $105 million to

the World Bank for PBF in developing countries. USAID’s

manual, Paying for Performance in Health: Guide to

Developing the Blueprint is used widely, including by the

World Bank for global training.

• Private Sector Loans. USAID leveraged $206 million in

commercial lending (which was 24 times the amount of

obligated funds) for private providers of reproductive

health, family planning, and other health services in

Nicaragua, Zambia, Nigeria, Peru, the Philippines, Romania,

and Uganda. 

• National Health Accounts (NHA). More than 100 developing

countries have applied NHA. Developing countries, rather

than donor agencies, planned the 6th global NHA symposium

in China in 2009. USAID work has attracted substantial

grant funding from the Bill & Melinda Gates Foundation to

this area of work. Countries such as Malawi and Rwanda

have used NHA results to improve health policy.

Leadership and Governance

• Health System Assessment Approach. Assessments are being

conducted increasingly as country-driven applications of

the methodology. In 2008–2009, the West Bank, Namibia,

Vietnam, Nigeria, and Senegal have adopted the approach.

• Private Sector Assessment Approach. Country application

creates awareness of enabling or constraining environments

for private sector participation in health, while providing

information for expanding policy dialogue and identifying

options for private sector market entry and growth. 

• Health System Action Network (HSAN). HSAN is a global

HSS peer network that is now routinely sought out by

global initiatives for advice and input.

• Virtual Leadership Development Program. Teams from the

public sector, NGOs, faith- and community-based organizations, and Cooperating Agencies from 53 countries in Latin

America and the Caribbean, Africa, Asia, and the Near East

have participated in the program since 2002. 

Service Delivery

• Making Improvement Part of Service Delivery. Using the

results of pioneering adaptations of modern Quality

Improvement (QI) approaches in developing countries,

local health providers are now carrying out the method.

• Quality Improvement Approaches. Using modern QI

approaches, it is possible to demonstrate that health service

delivery can improve even with no new resources by better

organizing the process of care. 

• Using market forces. USAID developed social marketing,

partnered with commercial corporations on profitable

models that reach the underserved, and brokered publicprivate partnerships to improve the efficiency of the health

system in increasing access to and quality of health products

and services.
Health Systems Report to Congress 59

ANNEX C. IMPLEMENTING THE WHO/PEPFAR 

TASK-SHIFTING RECOMMENDATIONS AND GUIDELINES

Background

The World Health Organization (WHO) and the Office of

the U.S. Global AIDS Coordinator (OGAC) established a

strategic partnership to provide a framework for PEPFAR

countries to strengthen and expand the existing workforce

to scale up HIV services through the use of “task shifting.”

Task shifting involves the rational redistribution of tasks among

health workforce teams. Specific tasks are moved or shifted,

where appropriate, from highly qualified health care workers

such as doctors and nurses to health workers with shorter

training and fewer qualifications in order to make more

efficient use of the available human resources for health.

In January 2008, Task Shifting Global Recommendations and

Guidelines were released by theWHO. Soon after, implementation and national scale-up of the guidelines was begun in

PEPFAR countries that expressed an interest in implementing

task shifting on a national level. At the end of FY 2009, 14 of

the 18 countries submitting a full country operating plan indicated that they had implemented the task shifting guidelines

in order to expand their health workforce capacity to deliver

HIV services. 

Policy change to allow for task shifting from more specialized

to less specialized health workers is the one human resources

for health strategy that will have the most significant and most

immediate effect on increasing the pool of health workers to

deliver HIV services.

The adoption of task shifting has the potential to rapidly

strengthen and expand the existing workforce to deliver HIV

services. The WHO task shifting global recommendations and

guidelines were developed in collaboration with PEPFAR, and

with PEPFAR support, to assist countries to address the clinical,

policy, regulatory, and financial frameworks needed to implement task shifting on a national level. 

Implementation

The recommendations and guidelines were widely disseminated

at a global consultation and made available through the WHO

Web site and through PEPFAR technical considerations, which

promote their adaptation and implementation in PEPFAR

countries. National scale-up is coordinated and carried out by

a national Task Shifting Working Group, with technical assistance

provided by WHO and relevant PEPFAR staff and implementers.

Successful implementation of task shifting requires a multisectoral approach, with all stakeholders involved in the

national implementation. The guidelines recommend that, in

each country where implementation or scale-up of task shifting is occurring, a National Task Shifting Working Group

should be established with participation from ministries of

health, education, and labor; USG teams; national academic

institutions; professional associations; regulatory bodies; and

civil society.

The priority components of country implementation include:

• Country adaptation of the global guidelines into the

national context, 

• Technical support for implementation of national training

and credentialing activities, 

• Development of supervision and mentoring systems to

ensure quality of service,

• Support for the development of enabling financial conditions

at the local level,

• Development of a monitoring and evaluation framework

including an economic analysis, and 

• Early evaluation of the implementation of the task shifting

approach.

PEPFAR is assisting countries to implement task shifting

through technical assistance by regional and in-country

human resources for health (HRH) advisors, country and

headquarters HRH technical working groups, implementing

partners, and collaboration with WHO regional and country teams.
60 Sustaining Health Gains – Building Systems

Evaluation

In 2009, PEPFAR provided support for a multi-country public

health evaluation (PHE) to assess the impact of task shifting

for the provision of antiretroviral therapy (ART) on patient

outcomes. Three countries – Nigeria, Uganda and Tanzania –

are participating in the evaluation, which, in addition to evaluating patient care and treatment outcomes, is expected to

assist countries to identify best practices for training and

supportive supervision necessary to safely implement task

shifting. This is a three-year PHE. Site selection and preparation

has begun, and countries are waiting for institutional review

board approval when nurse training and patient enrollment

will occur.
Health Systems Report to Congress 61

This report was written by the technical specialists 

who support the USAID health systems strengthening program.

Technical Team 

Jacob Adetunji Holly Fluty Dempsey Rachel Lucas Yogesh Rajkotia

Laura Harley Andes Forest Duncan Paul Mahanna Roxanna Rogers

Susanna Baker Bob Emrey Lisa Maniscalco Kelly Saldaña

Laura Birx Marguerite Farrell Jennifer Mason Lois Schaefer

Sarah Jonassen Bittman Jessica Forrest Chris McDermott Elizabeth Schoenecker

Anthony Boni Elizabeth Fox Maureen Norton Krista Stewart

Alan Bornbusch Roshni Ghosh John Novak Scott Stewart

Elizabeth Bowen Dale Gibb Ligia Paina Hope Sukin-Klauber

Robbin Boyer Benjamin Gustafson Kathryn Panther Janis Timberlake

Kimberly Cernak James Heiby Janet Phillips Susan Thollaug

Gloria Coe Mai Hijazi Jeffrey Picard Mary Vandenbroucke

Veerle Coignez Paul Holmes Willa Pressman Kristina Yarrow

Gary Cook Ishrat Husain Estelle Quain

The Communications Team of the Analysis, Information Management, 

& Communications (AIM) Activity designed and produced the report. 

Cover photo: © 2007 Requel Legaspino/AHP/ACS, Courtesy of Photoshare

ACKNOWLEDGEMENTS
U.S. Agency for International Development

1300 Pennsylvania Avenue, NW

Washington, DC 20523

www.usaid.gov