PURPOSE AND PRINCIPLES
The national response to the HIV and AIDS epidemic in Swaziland is led by the Government of the Kingdom of Swaziland (the GKOS) under the 2006 Multi-Sectoral HIV and AIDS Policy. It is coordinated by the National Emergency Response Council on HIV and AIDS (NERCHA), a statutory Council under the Office of the Prime Minister. To guide the response, a new National Strategic Framework on HIV and AIDS 2009-2014 (NSF) has been developed through a broadly consultative process involving key GKOS Ministries, bilateral donors, international partners and civil society. The NSF provides the overall goals and roadmap for the national response.
In 2008, the United States Congress reauthorized the President’s Emergency Plan for AIDS Relief (PEPFAR) for five additional years. The goals of this phase remain increasing access to antiretroviral therapy, preventing new infections and providing care to people affected by AIDS, including orphans and vulnerable children. In addition, this second phase of PEPFAR places greater emphasis on strengthening partnerships with host country governments and building capacity for a more sustainable response.
The purpose of this Partnership Framework on HIV and AIDS 2009-2013 (Framework) is to provide a five-year joint strategic agenda for cooperation between the GKOS and the Government of the United States of America (the USG) to support achievement of the goals of the NSF and in so doing, contribute to the PEPFAR goals for prevention, care and treatment. During this five year period, the priority thrust of the Framework is to rapidly scale up proven interventions throughout Swaziland to reach men, women and children with needed services and support. Key elements of the Framework include expanded and improved service delivery, policy reform and coordinated financial commitments. In addition to achieving enhanced service coverage and quality, the Framework aims to strengthen local capacity to sustain an effective response. The following principles guide Framework design, implementation and evaluation:
II. FIVE-YEAR STRATEGIC OVERVIEW
Twenty-six percent of Swaziland's adult population (15-49 years) is infected with HIV, while HIV prevalence amongst women attending ante-natal care facilities stands at 42 per cent. It is estimated that in 2009, 191,000 PLWHA, or nearly 20 per cent of the total national population, will require AIDS-related care and/or treatment services. Illness and death associated with HIV and AIDS are enormous drains on the national economy, national health system and other social support networks. Nearly one third of all children in Swaziland are orphaned or vulnerable and the growing need for child care and support exceeds the capacity of many families and communities.
In the face of these enormous challenges, the GKOS, with the support of its partners, has made significant progress over the last few years in the adoption of a multi-sectoral HIV and AIDS policy, the establishment of NERCHA as the national coordinating body, and the implementation of HIV-related prevention, care and treatment programs. Despite this progress, HIV prevalence has not declined and HIV-related services remain limited in reach due to social, economic and institutional constraints. Substantial investment and rapidly scaled up responses will be required to turn the tide on the epidemic and effectively mitigate its impact.
Over the last year, NERCHA led a broadly consultative process to review progress to date, identify priority needs and define key areas of investment for a scaled up response to HIV and AIDS. The outcome of this process is the NSF, supported by a wide consensus as the way forward. This Partnership Framework was developed in close consultation with GKOS and other key stakeholders to support the NSF in areas of U.S. comparative advantage. It is expected to be complemented by an implementation strategy to be set forth in a Partnership Framework Implementation Plan that describes targeted interventions and policy reforms, respective partner commitments, and monitoring and evaluation plans in greater detail.
The Framework intervention areas identified below are intended for rapid scale up in line with the NSF, the HSSP and the national policy on decentralization.
KEY INTERVENTION AREA: Decentralized and improved quality of care and treatment services for adults and children, including HIV testing and TB/HIV.
While considerable effort has been made to respond to the extensive health care needs due to AIDS and TB, there remain an enormous number of people for whom these services are currently inaccessible. The aim of this intervention area is to rapidly decentralize and improve the quality of HIV and TB-related care and treatment services as part of comprehensive care package to ensure that a greater number of PLWHA access needed services in a timely and effective manner. The USG is a major partner in the area of care and treatment, and efforts to scale up and improve services have already begun. Through this Framework, those efforts are expected to be significantly expanded in both the public and non-governmental sectors. In addition, the GKOS and the USG intend to improve human resources and promote policy reforms that focus on task shifting and health systems strengthening among other scale up priorities.
KEY INTERVENTION AREA: A coordinated and comprehensive approach to sexual prevention using social and behavioral change communication.
As stated in the NSF, HIV prevention remains the national priority for addressing the HIV epidemic in Swaziland. In spite of considerable program effort to date, new infections continue to overwhelm the number of persons placed on ART, making it difficult to halt and start reversing the epidemic. Current prevention efforts are not often well coordinated from national to community level nor are they sustained. There is a growing recognition that prevention efforts must move beyond individual behavior change to boldly address the social norms that fuel transmission. Through this Framework, the GKOS, the USG and other stakeholders seek to work together to create a comprehensive, evidence-based national prevention program that promotes effective social and behavior change through both the public sector and civil society. GOKS and PEPFAR intend to reconstitute the national Prevention Technical Working Group to provide national prevention leadership and coordination. The Framework is expected to focus on better linking innovative mass media approaches with sustained community-based prevention activities.
KEY INTERVENTION AREA: Rapid expansion of medical male circumcision (MC) to reach 15-24 year old males.
Leaders in the GOKS Ministry of Health took an early interest in the research showing the HIV prevention potential of MC and together with PEPFAR, UN agencies and other partners advanced policies, guidelines and implementation plans for national scale up. With current circumcision rates of only 8 per cent, tremendous effort will be needed to build up a skilled work force, high quality service delivery sites, effective communication strategies and monitoring systems. Through this Framework, the GOKS and the USG intend to invest in these areas to ensure achievement of the NSF goal to reduce HIV transmission by circumcising 80 per cent of 15-24 year old males within 5 years. For longer term sustainability of results, introduction of neonatal MC is also planned with the support of UNICEF and other partners.
KEY INTERVENTION AREA: Impact mitigation focused on vulnerable children and their families.
The needs of orphans and vulnerable children in Swaziland are immense and growing, while support services are often fragmented and inadequate. Impact mitigation is a priority focus of the NSF, and PEPFAR intends to engage as a new national partner in impact mitigation with a focus on vulnerable children. GOKS, PEPFAR and other partners have reviewed current programs and identified important opportunities for the USG to engage. Through this framework, GOKS, PEPFAR and other partners intend to initiate a process to develop and implement national program standards and strategies for quality improvement, enhance program monitoring and scale up quality services and support for vulnerable children. Framework interventions will work through and improve existing mechanisms and coordination structures for service delivery. The Framework is expected to support community-based, family focused services that target children at different developmental stages.
KEY INTERVENTION AREA: Development of human and institutional capacity to manage an effective HIV response, including aspects of strategic information.
The HIV response in Swaziland is seriously hampered in all program areas by limited human and institutional capacity. The HSSP underscores the need to upgrade and expand its health work force, to decentralize services and to build capacity of the supportive health network. Capacity development is a significant, cross-cutting focus of the Framework to ensure that the results achieved can be sustained. The USG has assisted with the introduction of a Human Resources (HR) information system and building capacity for laboratory services, pharmaceutical management and other key support systems. Through this Framework, the GKOS and the USG expect to further strengthen HR capacity in the areas of HR management, policy reform, recruitment, retention and training and to build institutional capacity across program areas through management systems strengthening and enhanced infrastructure.
The USG has made substantial investments to date in the national programs to prevent mother to child transmission (PMTCT) and to ensure a safe and adequate supply of blood. The USG plans to continue to partner with the GKOS through the Framework period to strengthen these two important program areas as follows:
III. PARTNERS' ROLES AND COMMITMENTS
The central partners for this Framework are the GKOS and the USG. Overall GOKS leadership for the Framework rests with the Office of the Prime Minister, which oversees all Ministries of Government. Based on consultation with the USG, the Office of the Prime Minister has, through a Cabinet decision, assigned the entities listed below to actively partner with the U.S. inter-agency PEPFAR team on the development, implementation and monitoring of this Framework2. It is recognized by both governments that the Offices and Ministries listed below are those primarily responsible for the proposed areas of engagement and partnership:
Within the U.S. Embassy, the Ambassador has overall leadership responsibility while the inter-agency PEPFAR team is responsible for design, implementation, and program management and monitoring.
Although signature of this Framework rests solely with the GKOS and the USG, the spirit of the Framework is inclusive and consultative. Achievement of the Framework's objectives is dependent on the roles and contributions of several key stakeholders (including GFATM, civil society leadership, United Nations (UN) agencies, international foundations and NGOs). The table below broadly describes the Framework objectives and the commitments of the GKOS, the USG and other partners. These are planned commitments that have been reinforced through ongoing collaboration and consultation.
GKOS intends to:
PEPFAR intends to:
Other Partner Roles
Care and Treatment Decentralize and improve the quality of treatment services within a HIV and AIDS comprehensive care package to increase access and improve outcomes
By 2013, 60,000 people living with HIV and AIDS (PLWHA) should be receiving high quality ART services*
* This target is based on the 2009-2013 NSF, and represents a GKOS national goal. PEPFAR is among the partners that will support the GKOS's efforts to achieve this goal. National coverage baseline for 2009 is 38,000 from GKOS statistics.
Provide leadership and coordinate partners for care and treatment
Approve and adopt specific policies for effective roll out of service delivery, including task shifting and community based care
Operate public health facilities, including laboratory and central medical stores
Operate adequate quality assurance and strategic information systems
Assist with the development of policies, guidance, training and quality assurance to promote decentralization
Provide for management and leadership development
Invest in infrastructure development and service provision in an expanded number of care and treatment facilities
Strengthen systems for laboratory services, pharmaceutical management and strategic information
GFATM: Funds for drug procurement and storage, training,
WHO: Technical assistance
Clinton Foundation: training, commodities, technical assistance
Italian Cooperation: technical assistance, laboratory support
Médecins Sans Frontières, Red Cross: Service Delivery support
UNICEF, Baylor: Pediatric care and treatment
Sexual Prevention Reduce behaviors that increase the risk of HIV infection and increase protective behaviors in the general population
By 2013, six per cent of males should report having multiple concurrent partners within the last 12 months*
* Based on the 2009-2013 NSF. Baseline is 23 per cent from most recent Swaziland Demographic and Health Survey (SDHS, 2007)
Strengthen national leadership and coordinate partners for prevention
Coordinate implementation of the national social and behavior change communication strategy for HIV prevention
Manage public sector condom distribution
Enhance public sector life skills curriculum
Conduct serological and behavioral surveillance programs
Provide for leadership and management capacity development in prevention and support the prevention TWG
Assist in the design and roll out of the national prevention strategy, including mass media
Support more unified community-based prevention efforts and programs targeting special populations
Support private sector condom distribution
Support GKOS surveillance programs
GFATM: Support to strengthen national capacity for prevention
GFATM, UN agencies, Southern African Development Community (SADC) and the United Kingdom’s Department for International Development (DFID): support behavior change and youth programs
GFATM and UN agencies: support condom programs
Medical Male Circumcision (MC) Ensure that 80 per cent of males aged 15-24 years are safely circumcised*
* Based on the 2009-2013 NSF. Baseline is 5 per cent from the most recent Swaziland Demographic and Health Survey (SDHS, 2007)
Provide leadership and coordinate partners through the Task Force
Adopt the MC policy and communication strategy and coordinate their implementation
Build physical and human capacity to deliver scaled up MC services
Establish and operate routine monitoring and evaluation system for MC
Support the MC Task Force
Assist the MOH to expedite recruitment; fund MC coordinator and limited term providers
Support MC communication; training and service delivery
Support routine monitoring and program evaluation for MC
Bill and Melinda Gates Foundation (BMGF): provide resources to support MC scale up, including Task Force, communication, human resources and service delivery needs
WHO: Provide technical assistance
UNICEF: Support neonatal circumcision pilot and expansion
By 2013, 50 per cent of vulnerable children should be receiving at least three basic support services on a continuous basis
* In this program area, the Framework intends to strengthen program standards, baseline data and monitoring systems. This objective is derived from the NSF based on the most reliable national indicator, and is intended to be monitored through periodic SDHS and QUIMS (Quality of Impact Mitigation Survey).
Provide leadership and coordinate partners; Operate the NCCU and DSW
Adopt and implement key policies related to children, including the Children's Bill
Establish standards and a monitoring and evaluation framework for programs that target vulnerable children
Provide support services through various public facilities
Provide education grant for orphans and vulnerable children while planning for free basic education
Support roll out of the Children's Bill and other key policies
Support development of service standards and monitoring and evaluation framework
Provide services and support to vulnerable children through neighborhood care points
Support expansion of the work of the child protection network
Support Peace Corps Volunteers and NGOs to provide family-centered services and support to vulnerable children
GFATM: Provide funds for construction of neighborhood care points and community caregivers
UNICEF: Further develop the capacity of the NCCU and DSW, support the neighborhood care points, child protection network and school based programs
Save the Children, World Vision and other NGOs: Coordinate the child protection network, provide family-centered community level services
World Bank: Support measurement of Impact Mitigation Service Standards
Capacity Development Improve the human and institutional capacity of the MOH and NGOs to respond to the HIV epidemic
By 2013, 80 per cent of established positions in the Ministry of Health should be filled*
* MOH and PEPFAR intend to establish a reliable baseline for this indicator as part of Framework efforts. The objective was established by MOH and PEPFAR
Build capacity of the HR unit in the MOH; finalize and implement HR and organization structure; decentralize, operate HR information system
Recruit and retain adequate MOH workforce; Standardize cadres of community workers
Develop performance-based supervision
Coordinate and provide oversight for NGOs working on HIV programs
Support the HR unit at the MOH and the HR information system
Provide HR training and technical assistance to expedite recruitment, improve performance and increase retention
Fund additional staff for short term scale up needs or as a precursor to absorption by GKOS
Provide capacity development support to local NGOs working on the HIV response
World Bank and European Union: Plan to develop complementary support to strengthen human resources for health
UN Agencies, International NGOs and others are implementing various, limited capacity development initiatives to support the HIV and AIDS response
IV. FINANCIAL CONSIDERATIONS
The USG and the GKOS recognize that resources are limited and that financial commitments are subject to the availability of funds. It is further recognized that achievement of the Framework goals requires resource flows beyond the ability of any one partner, and that constraints on availability of funding from either signatory or from other key partners could lead to a review and revision of the goals.
If U.S. assistance is provided directly to GKOS under this Framework, GKOS contributions would be expected to meet host country cost sharing requirements under U.S. foreign assistance programs. Details regarding the GKOS and U.S. financial and in-kind contributions to programs under this Framework are to be provided in the Partnership Framework Implementation Strategy.
V. MANAGEMENT, MONITORING AND COMMUNICATIONS
To date, the relationship between the GKOS and PEPFAR has been one of collaboration and mutual respect. The Framework presents an opportunity and an instrument to further strengthen collaboration, coordination and accountability by ensuring a focus on key mutually defined strategies and measures of success. The governance system to manage the Framework builds on existing structures already in place to provide oversight for the national HIV response.
Technical Oversight and Monitoring: Within GKOS, NERCHA is expected to have primary responsibility for monitoring Framework implementation based on a mutually defined monitoring and evaluation plan. Within the USG and in each of the assigned GKOS Ministries, a point of contact is tasked as liaison to manage and routinely monitor the relevant elements of the Framework. The existing Technical Working Groups for Care and Treatment, Prevention and Impact Mitigation are intended to provide the periodic vehicle for ensuring that Framework interventions are up to date and in line with the goals of the NSF.
Strategic Oversight: In a new formalized structure, the full team of GKOS and PEPFAR management leadership intend to meet annually bringing in leadership from civil society, UN agencies, private foundations, the private sector and other bilateral assistance agencies as appropriate to discuss progress towards goals and objectives. A progress report is intended to be developed by this GKOS-PEPFAR team and disseminated to participants at the annual meeting and to all other stakeholders, including the public.
Global Fund harmonization: At the quarterly full meeting of the GFATM Country Coordinating Mechanism (CCM), members intend to review the integration of the Framework activities with Global Fund grants and national priorities.
High level oversight: This is expected to be provided through meetings between the Prime Minister of Swaziland and the U.S. Ambassador.
Modifications to this Framework may be made in writing with the consent of all signatories.
1 For efficiency, rapid action and measurable results, the Three Ones Principles promote one national AIDS Action Framework, one National AIDS Coordinating Authority, and one national monitoring and evaluation system.
2 Please see attached Cabinet Decision dated 17 March 2009.
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