Addressing health workforce challenges: Lessons learned and future directions Rifat Atun Mary Ann Lansang Strategy, Performance & Evaluation Cluster The Global Fund to Fight AIDS, Tuberculosis and Malaria

Outline Health workforce challenges Global Health Workforce Alliance, Positive Synergies Global Fund experience Country examples from Global Fund grants Lessons learned and future directions

Health workforce Strong and effective health workforce is essential in any effort to scale up Global deficit of trained health workers ~4.3 million Increasing demand for health services: –Countdown to 2015 and the MDGs –Significant investments and new resources for targeted programs through Global Health Initiatives –Inequities in health workforce distribution –Emerging and re-emerging infections –Growing problems of noncommunicable diseases and global warming A key component of health systems strengthening

AIDS and the health workforce Increasing no. of people requiring care ART for 1,000 people, would need:  1-2 physicians  2-7 nurses,  1 – 3 pharmacy staff,  many counsellors and treatment supporters (Hirschhorn, 2006) Healthcare providers often not providing optimal care: –Stigma associated with AIDS –Absence from work to care for sick family member/s –Infected themselves –Attrition: death, resignation, brain drain, retirement Potentially more people needing treatment as CD4 count threshold for ART is being reconsidered Challenges of TB/HIV co-infection

Capacity development for the health workforce Policy environ- ment Health facilities Health work- force Com- munity Effective HR policies Staff recruitment & retention policies/procedures Policy measures for effective response to HIV/AIDS Training & utilization of CHWs Skills training Pre-service education Quality management Leadership development Adequate drugs & commodities Supportive infra Info management systems

Health workforce and global challenges Global Health Workforce Alliance, Positive Synergies Global Fund experience Country examples Lessons learned and future directions

Global Health Workforce Alliance Leadership in broad aspects of the human resources crisis Health Action Framework Task Shifting collaboration with WHO, UNAIDS and PEPFAR Extension of scope of practice of of available human resources Enabling environment

Positive Synergies: On the health workforce Scale-up of priority interventions has not matched corresponding expansion of health workforce Urban-rural health workforce imbalances GHI investments in human resources focused on: –in-service training for disease-specific programs –task-shifting –increasing numbers of less qualified health workers who require limited training More ambitious action needed to address long-term human resources shortages

Positive Synergies: On the health workforce (WHO Maximizing Positive Synergies Collaborative Group, Lancet, June 2009) Scale-up of disease specific efforts has increased the burden on the existing health workforce GHIs have strengthened the existing workforce through in-service training and task shifting GHIs have not invested substantially in pre-service education for the production of new health workers others than CHWs GHIs are associated with some attrition of the health workforce from the public sector to specific non-state sector projects funded by them In some instances, GHIs have contributed to improving the retention of health workers through various incentives, including supplemental salary, housing and other allowances From: Lancet, June 2009

Maximizing Positive Synergies (Venice Concluding Statement on Maximizing Positive Synergies between Health Systems and GHIs, Venice, Italy, 23 June 2009) Need for further research to inform policy and actions… Urgent need to develop and strengthen the health workforce through increased education and training as well as strategies to sustain and retain all categories of health workers. Central role played by communities and the need to build up their capacities to contribute to the planning and delivery of health services. Development partners: further reduce duplication and fragmentation through more effective alignment of planning processes and resource allocations with country health systems.

Health workforce Global Health Workforce Alliance, Positive Synergies Global Fund experience Country examples from Global Fund grants Lessons learned and future directions

HSS funding by the Global Fund Approach to HSS in Round GuidelinesGenerated Demand for HSS Investments Rounds 1-3: could request funding for “cross-cutting issues” relevant to the three diseases. Round 4: could request separate funding for ‘integrated’ HSS activities for a ‘comprehensive response’ to the 3 diseases (focus on system-wide approaches and cross-cutting aspects to strengthen health systems). Round 5: ‘integrated’ component renamed to HSS.  HSS proposals (N=30)  10% approval rate (3 HSS grants) Round 6: HSS activities ‘integrated’ into disease proposals. Round 7: Applicants asked to identify health system 'strategic actions‘ linking them to a disease proposal (15 categories)  Demand for HSS investments - USD 912 million over 5 years.  39% funding approval rate (USD 363 million) Round 8: HSS activities specified in a distinct cross-cutting HSS section attached to a disease proposal. (WHO HSS ‘building-block’ categories)  Demand for HSS - USD 1,236 million over 5 years  48% funding approval rate (USD 593 million)

n = 24 grants

Health workforce budgets in Round 8 HSS proposals (n = 49 successful/unsuccessful proposals) Health workforce share of total budget: 21% Main cost items: –In-service training at sub-district level –Some management training in supervision –40% for recruitment incentives and salary supplements (including bonuses and performance-based mechanisms)

Health workforce gaps and wage bill agreements in 12 African countries (Ooms et al. 2007)

National Strategy Applications Objective: To increase aid effectiveness (alignment, harmonization, mutual accountability and results focus) by having partners mobilize around a single common agenda – the development, financing and implementation of robust national strategies Invitees determined based on: Strategy with timeframe at least until 2012 No successful R8 application for the same disease + judgment from partners & GF Country Programs 23 invitations – HIV: 9 countries 7 submitted 3: successful desk review 4: Rd 9 proposal deadline extended NSA workshop (May 2009) Country visits

Health workforce Global Health Workforce Alliance, Positive Synergies Global Fund experience Country examples from Global Fund grants Lessons learned and future directions

The Malawi Experience (1) Key to success - country’s concerted and strategic effort to roll out three related schemes: 1.The health sector wide approach and joint program of work ( ) 2.The six-year emergency pre-service training plan launched in The Emergency Human Resources Program of 2004 (undertaken in partnership with DFID and SWAp) In Phase 2, Malawi able to reprogram US$40 M of the Global Fund grant to support expansion of health workforce, including supplemental salary support.

The Malawi Experience (2) Notable features: Global Fund flexibility in supporting health workforce Emergency HR program extended to form part of the national health plan Regulations modified to allow nurses to prescribe ARVs Active engagement and negotiations with IMF re macroeconomic policies Mortality reduction among health workers

The Ethiopia Experience Large scale community mobilization through Health Extension Program More recently, working in partnership with GHIs, investments in: –Accelerated health officers training program and clinical mentorship –Masters program in surgical emergency and obstetrics –Medical pre-service education for production of new health workers –Training of data clerks deployed to health facilities Strong governance and leadership to support comprehensive approach to implementation Policy and regulatory reforms –Costing of each intervention –Health Service Delivery Proclamation –Strengthening of human resources for health section of Parliament Draft Professional practice laws

Health workforce Global Health Workforce Alliance, Positive Synergies Global Fund experience Country examples from Global Fund grants Lessons learned and future directions

Lessons learned Much remains to be done: –Unabated and increasing demands on the health workforce in the context of unmet targets for the MDGs, new HIV/AIDS challenges and the global economic crisis. –Gaps and weaknesses in health workforce will limit scale-up. –Inadequate investments in tapping community systems for health services. There is hope: –Country-driven strategies, backed up by medium- to long-term HR development plans, and supportive policy and regulatory frameworks. And there are enablers: –Flexibility in grant support for the health workforce to respond to country demand for scaling up health services. –“Sustainability” in the context of low-income countries: long-term and predictable international support for health systems strengthening (a long-haul process). –New instruments can potentially increase sustainability (e.g., National Strategy Applications, new grant architecture)

Future directions (1) Really getting our act together: Harmonization and creative partnerships at the global level –Maximizing Positive Synergies and the Global Health Workforce Alliance –Apply common frameworks and definitions –A menu of options and approaches for countries and partners –Harmonizaton of investments where possible –Build on comparative strengths

Future directions (2) Learning together: –First Learning Wave from the Global Fund’s national strategy applications –Country case studies with a common set of tools –Context-specific solutions to health workforce issues related to recruitment, training and quality management, retention and welfare –M & E tools for health workforce interventions –Finding the right balance between responses to immediate bottlenecks vs. long-term approaches Sustained resource mobilization for health systems strengthening

Acknowledgments Various contributions from Global Fund colleagues: Rebecca Bailey Pauline Brocard Daniel Low-Beer George Shakarishvili Kirsi Viisainen