From 2000 to 2006, the Partners for Health Reformplus (PHRplus) project was the U.S. Agency for International Development's (USAID) flagship project in health policy and systems strengthening.  USAID looked to PHRplus to provide technical assistance in, and to help maintain USAID's worldwide leadership role in health care reform and improving health system performance.  By enhancing health system performance in developing and transitional countries, PHRplus increased the use of high-quality, sustainable priority health services, particularly by those at greatest risk — women, children and the poor.  Abt Associates implemented PHRplus with the assistance of eight partner organizations, 14 local institutions, and dozens of developing country consultants.  The program spanned 28 countries and five continents, involving all six of USAID's regional bureaus.  PHRplus built upon the predecessor Partnerships for Health Reform project (1995-2000), continuing USAID's focus on health policy, financing, and organization with a new emphasis on community participation, infectious disease surveillance, and information systems that support the management and delivery of appropriate health services.  In addition to providing technical assistance and supporting USAID's leadership role, PHRplus conducted health systems research; implemented performance monitoring and results tracking; provided training and capacity development; and was responsible for strategic documentation and transfer of experience in health policy and systems strengthening. The accomplishments of PHRplus fall into several thematic areas.

Community-Based Health Financing PHRplus sought to make health care more affordable and accessible — by providing technical assistance to community-based healthcare financing (CBHF) schemes.  A CBHF scheme is managed and operated by a private non-profit entity such as a village or professional association, which provides risk pooling to cover part or all of the costs of health care services.  Enrollment is voluntary and the scheme can cover a variety of benefit packages often determined by the members.  PHRplus augmented the growth in the number of CBHF schemes, particularly in West and Central Africa, where the number of schemes expanded from 76 in 1997 to 366 in 2003.  PHRplus support for CBHF schemes in West Africa provided several hundred thousand members with access to a wide array of health services.

HIV/AIDS PHRplus contributed critical technical input to the fight against HIV/AIDS at the global and country levels, increasing attention on financing and sustainability issues and improving policies.  As countries expanded access to antiretroviral treatment (ART), PHRplus helped policymakers plan and estimate the costs of comprehensive ART programs.  In 2002, PHRplus collaborated with the Policy Project to estimate the cost of scaling up ART in several African countries to inform the design of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR).  PHRplus also helped to facilitate ART scale-up by analyzing and addressing constraints on human resources and information systems.  Additionally, PHRplus developed and applied a software model that used country-specific data to help governments craft realistic, evidence-based cost estimates for national ART policies and programs.  The model was used to inform policymakers in Uganda, Nigeria, and Mexico.  PHRplus also launched the international research network "SWEF" to study the effects of the large influx of HIV/AIDS funding on the larger health system.

National Health Accounts National Health Accounts (NHA) is a method for measuring total public and private health expenditures.  As health systems grow and become more complex, planners and policymakers need tools to analyze health financing to understand their own systems and to make comparisons with the experience of other nations.  NHA is being used today in more than 100 low- and middle-income countries, many of which were supported by PHRplus.  The project facilitated the institutionalization of routine NHA data collection in countries such as Egypt, Jordan, and Morocco.  PHRplus also helped to ensure that NHA data were used to inform health policy in numerous countries, including Guatemala, Jordan, Kenya, Malawi, Morocco, Rwanda, and Tanzania.

Collaboration with and Leveraging of Global Initiatives Through PHRplus, USAID coordinated with donor agencies and programs to leverage resources, avoid redundancies, and enhance impact.  PHRplus provided critical technical input into global health initiatives like the Global Alliance for Vaccines and Immunization (a tool for country financial sustainability analysis), and the Roll Back Malaria (RBM) Partnership (costing of Artemisinin treatment and malaria expenditure tracking).  PHRplus fostered collaboration at the country level as well.  In Peru, the program leveraged Inter-American Development Bank funds to apply a targeting methodology developed for the health sector to all social and poverty alleviation programs.  In Yemen, PHRplus collaborated with UNFPA to establish a midwives association.  Additionally, WHO/AFRO adopted a costing protocol developed by PHRplus in Tanzania as the model on which future costing research in infectious disease surveillance would be based.

Infectious Disease Surveillance Infectious disease surveillance and response involves systematic collection, analysis, interpretation, and dissemination of data to health workers and others to contain the spread of disease.  PHRplus improved disease surveillance and control by creating national policies and standards for reporting and responding, including the adoption in African countries of the WHO/AFRO integrated disease surveillance and response (IDSR) methodology.  In Georgia, Ghana, and Tanzania, the program improved health worker capacity, efficiency, and motivation at facility, district, and regional levels through training, software tools, and job aids.  PHRplus also strengthened linkages and communication across levels and vertical programs.

Accountability Accountability ensures that services are responsive to patients; that health system actors are responsive to communities; that funds are properly used; and that reform efforts improve health system performance.  In the Democratic Republic of Congo, PHRplus conducted case studies of the governance of semi-autonomous health zones and recommended a rethinking of the charter that governs their operation.  In Peru, PHRplus assisted with the implementation of citizen referenda to set health priorities for regional authorities.  In Senegal and Benin, the program helped national governments develop strategies for promoting community-based health financing that preserves the community accountability features of schemes.  PHRplus contributions to accountability also included the development of information systems; technical assistance on contracting and other components of transparent provider payment; and facility and household surveys to inform policy, identify barriers to service delivery, and ensure the quality of care.