Addressing health workforce challenges: Lessons learned and future directions

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

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

3. 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

4. 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

5. Capacity development for the health workforce • Effective HR policies • Staff recruitment & retention • policies/procedures • Policy measures for effective • response to HIV/AIDS • Skills training • Pre-service education • Quality management • Leadership development • Adequate drugs • & commodities • Supportive infra • Info management • systems • Training & utilization of • CHWs

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

7. 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

8. 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

9. 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.

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

11. HSS funding by the Global Fund

12. n = 24 grants

13. 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)

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

15. 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

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

17. The Malawi Experience (1) Key to success - country’s concerted and strategic effort to roll out three related schemes: The health sector wide approach and joint program of work (2004-2010) The six-year emergency pre-service training plan launched in 2002 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.

18. 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

19. 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

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

21. 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)

22. 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

23. 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

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