Results and conclusions

- The scale-up of antiretroviral therapy (ART) for HIV has not followed a systems approach and is currently distorting rather than strengthening health systems

- The intention to aim at better integration has not yet materialized leading to lost opportunities to synergistically strengthen the health system across all building blocks

- Parallel, vertical donor and program structures for ART require multiple reporting systems, compete for scarce human resources for health (HRH) and rely on separate systems for distribution of drugs and supplies.

- Despite a considerable increase in national health expenditures on HIV, there is a relatively low pass through of fungible decentralized funds to the district level and ARV budgets are not part of the District Health Plan inhibiting local ownership and planning.

- ART scale-up has not served as a catalyst for dealing with the HRH crisis and there is accelerated brain drain of health workers away from the public health sector to HIV-related NGOs, i.e. internal brain drain.

- Many HIV-related training activities (with sit-in allowances) lead to staff absenteeism and work overload on remaining staff for other services.

- There has been a rapid increase in the number of enrolled patients on ART and appointment adherence is high. However, the uptake of pre-ART care is still low leading to late treatment initiation.

- Poor supply chain management leads to frequent stock-outs of essential drugs including ARVs and cotrimoxazole causing treatment interruptions and delayed enrollment

- Significant HIV and ART related stigma persists, and separate HIV clinics are seen as stigmatizing.  Post-test counseling needs more attention.

- Laboratory testing is fairly well-decentralized with an overall increase of lab activities but the quality of testing needs to be improved and reagent shortages are frequent.

- Referral systems for HIV testing and prevention of mother to child transmission (PMTCT) from antenatal care facilities that lack HIV testing on site are insufficient and few complete the full PMTCT programme despite high antenatal care coverage.

- PMTCT scale-up has failed to improve the quality of non-PMTCT maternal services for pregnant women and the overall capacity of maternal and child health care appears to suffer.

High overall completeness of health information systems and reporting, but low promptness compromise the use of data for decision-making.



Karolinska Institutet, Sweden
Karolinska Institutet

Makerere University, Uganda
Makerere University

Swiss Tropical Institute
Tropical Institute

The Ifakara Health Institute, Tanzania
The Ifakara Health Research and Development Center - Tanzania

Insititute of Tropical Medicine Antwerp, Belgium
Prince Leopold Insititute of Tropical Medecine

University of Heidelberg, Germany
University of Heidelberg

Centre de Recherche en Santé de Nouna, Burkina Faso
Centre de Recherche en Santé de Nouna Demographic Surveillance System Site