Seite 1 PROJECTS IN THE REGION: Horizontal Cooperation on HIV/AIDS (CICT/GTZ) GTZ Backup Initiative (Support for preparation of proposals for international initiatives such as the GF and capacity building) Technical support based on: The “3 ONES” principle: one political authority, one multisectoral program, and one M&E system The Paris Declaration agreements

Seite 2 STRENGTHENING THE HEALTH SYSTEM TO RESPOND TO HIV/AIDS AND TUBERCULOSIS CROSS-CUTTING COMPONENT PARAGUAY PROPOSAL AT GLOBAL FUND ROUND NINE Dr.Manuel Mancheno (GTZ Project Manager) Dr. Maria Gloria Montórfano (Consultant—GTZ Backup Initiative)

Seite 3 Seite 3 PROPOSAL OBJECTIVES GENERAL: Ensure the sustainability and expanded coverage of the outcomes achieved by the HIV/AIDS and tuberculosis programs, with the support of the GF projects (HIV/AIDS: rounds 6 and 8 and Tuberculosis: rounds 3 and 7). SPECIFIC:  Develop a strategy to increase the effectiveness of the response to the HIV/AIDS and tuberculosis epidemics.  Shift the model of care from a biomedical approach to a biopsychosocial approach and from the individual to the family and community, based on PHC.  Adopt a horizontal approach for controlling the multiple determinants of the HIV/AIDS and tuberculosis epidemics.

Seite 4 Seite 4 OPPORTUNITY  New model of care and new model for service delivery, with emphasis on primary care.  Participation and decentralization policy.  Availability of a plan to strengthen the national health system.  Achievements of the HIV/GF projects approved in round 6 and the tuberculosis projects approved in rounds 3 and 7, which have led to the approval of financial resources in different phases of the project.

Seite 5 Seite 5 The HIV/AIDS and tuberculosis programs: Meet objectives and specific goals agreed upon with the GF, rather than country goals. Provide fragmented services in the health system, leading to duplication of services and parallel systems. In special financial and human resources conditions, improve care and prevention indicators in key populations and specific geographic areas; not enough for an effective national response. ANALYSIS

Seite 6 Seite 6 SITUATION EXAMPLE Round 6 of the GF: 80% of pregnant women who visited the health service were reached (project goal). Each year, the prenatal program only reaches 55% of the pregnant women who use the health system. Resulting national coverage of PMTCT is 42%.

Seite 7 Seite 7 CONVERGENCE ANALYSIS Program Convergence with STD/HIV/AIDS Function, Provision of Service Reproductive Health Logistics and supplies Prenatal care Family planning Procurement, storage, and distribution of medicines and supplies Procurement, distribution, storage, and provision of the supplies needed for STD/HIV/AIDS and tuberculosis care 80% of HIV cases are sexually transmitted, and 10% are transmitted through the perinatal route or through breastfeeding

Seite 8 Seite 8 PROPOSAL 1.Financial support to cover the expenditure gap resulting from the integration of HIV/AIDS and tuberculosis benefits into the PHC and ambulatory services network. 2.Improve HR policies for health systems. 3.Strengthen PHC services, considering that 80% and 90% of users of these programs go to their first visit to address some problem or symptom directly related to HIV/AIDS or tuberculosis. 4.Coordination with the GF’s priority objectives and goals in HIV/AIDS and tuberculosis (previous rounds) to employ good practices and coverage with a country vision.

Seite 9 Seite 9 THE PROPOSAL 5. Support the development of public National Health System to reduce the high degree of inequity in access to health services and the fragmentation of the system through service networks: Principal networks: Primary Health Care Network, Ambulatory Care or Specialized Polyclinic Network, Emergency Network, and Hospital Network. These four networks will be coordinated through a communications system and a regulatory system. Supplementary networks: Pharmacological Assistance Network, Health Surveillance Network, Rehabilitation Network, and Diagnostic Support Network.

Seite 10 Seite 10 DIFFICULTIES National HIV/AIDS and tuberculosis programs are: service providers, human resource managers in the health services; and solely responsible for procuring and distributing supplies. Other vertical programs consider that assuming responsibility for HIV/AIDS and tuberculosis means working for a third party. The WHO HSS strategy is being used mechanically, without analyzing the sustainability and expansion of coverage that could be obtained by horizontally integrating HIV/AIDS and tuberculosis services in the Paraguayan health system.

Seite 11 Seite 11 ACHIEVEMENT: The Review Committee recommended financing the health system strengthening proposal presented in round 9 to the GF; it will be the first in the region.