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Financing health workforce

Financing health workforce. Dr Gülin Gedik Department of Human Resources for Health World Health Organization, Geneva. Distribution of health workers by level of health expenditure and burden of disease, by WHO region. Source: WHR 2006.

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Financing health workforce

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  1. Financing health workforce Dr Gülin Gedik Department of Human Resources for Health World Health Organization, Geneva

  2. Distribution of health workers by level of health expenditure and burden of disease, by WHO region Source: WHR 2006

  3. Investment in HRH required to expand health workforce! World Health Report 2006 • US$ 10 per capita increase in health expenditure to train and recruit the health workers Task Force on Scaling up Education and Training (2008) estimated • US$ 26.4 billion is required over 10 years to train 1.5 million health workers required in Africa (Shortage in SEAR and WPR is approximately 1.2 million) Scheffler et al. 2009 • approximately US$ 20 billion is needed to scale up HRH in Sub-Saharan Africa by 2015

  4. How much is spent on health?Total health expenditure on health as % of GDP (2009) <3 3.1 -5 5.1- 8 8.1 -10 10.1-13 >13:0 N/A No data Source: Global Health Observatory

  5. Health expenditure in EMR Source: EMR Statistical Information System (EMRSIS)

  6. How much can the public sector spend on health?Per capita expenditure on health, US$ (2009) Source: EMR Statitistical Information System (EMRSIS)

  7. Total health spending in some countries, 2009 Source: Global Health Observatory

  8. How much can the public sector spend on health?Government health expenditure on health in some countries Source: Global Health Observatory

  9. Private expenditure on health as a percentage of total expenditure on health, 2009 Source: Global Health Observatory

  10. Private expenditure on health in some countries, 2009 Source: Global Health Observatory

  11. Armenia:Financing statistics THE = Total Health Expenditure GGHE = Gross Government Health Expenditure OOP = Out of Pocket Payment GGE = Gross Government Expenditure PvtHE = Private Health Expenditure

  12. Proportion of each source of funding for health expenditure in Mozambique, in US$ million Source: Vertical funding report, 2008

  13. Remuneration of health employees • Average remuneration of health employees as share of total health expenditure : 11 -40 % • Average governmental remuneration to health workers as share of GGHE : 27 – 33 % Source: Presentation by D. Evans at Second Global Forum on HRH, Bangkok 25-29 January 2011

  14. HRH expenditure • Kenya – 65% of recurrent budget 47% of recurrent + capital budget 20% of recurrent + capital budget +donor assistance+ user fee income • Liberia 5% to training institutions • Mozambique 8% pre-service training

  15. How do salaries for HRH compare to other job categories?Turkey: Ratio of HRH earnings compared to other professions

  16. When health workers are employed as civil servants and their salaries are paid out of the overall government wage bill, the ministry of health has little authority over its salary budget. • Authority over the health wage bill budget usually lies with the ministry of finance • The ministry of health does not have effective control over a large portion of its total budget Source: Vujicic, M. et all. Working in Health. World Bank, 2009

  17. Health workforce as part of overall civil service • Health tends to make up only 5-15% of the overall civil service • Fiscal impact of increased health worker salaries or hiring is small • Education sector is 2-10 times larger • Scaling up the health workforce requires either reallocating salary budgets away from other sectors toward health or increasing the overall wage bill. Both are challenging. Source: Vujicic, M. et all. Working in Health. World Bank, 2009

  18. How do salaries compare to salaries in countries that receive migrants? : Ratio of physician wages (PPP, US$), destination country to source country Vjucic, et al. Human Resources for Health, 2004, 2

  19. Wage as a determinant of health worker density Cameroon Ghana South Africa Uganda Source: Vujicic 2004

  20. Non-wage incentives • Free education for children • Subsidized housing, meals • Subsidized health insurance, pension insurance • Free antiretroviral treatment • Provide loans/scholarships for health care studies • etc

  21. Projecting funding requirements for HRH: Costing HRH plans A cost estimate for implementation of HRH plan helps identifying financing gaps and serves as an advocacy tool for mobilizing resources Steps in costing an HRH planning costs: • Estimate current and projected staff • Estimating the number of additional staff need • Multiplying those numbers with current and future salaries and allowances • Estimating training costs (capital and recurrent) • Calculating financial needs on the basis of projected available funds • Discussing financing options

  22. Illustration of rationale of the Mozambique HR costing model Source: Tyrrell, 2008

  23. More funds in aid to health… Source: OECD-DAC. Measuring aid to health, November 2009

  24. …but, still low spending on HRH Source: OECD/DAC Statistics – Health ODA commitments – income groups 2002/2006

  25. Magnitude of health ODA in some countries

  26. Magnitude of health ODA in some African countries

  27. Alignment to national policies • HRH is priority in all countries where case studies were undertaken – why no adequate support? • not asked • not asked clearly enough and on a credible way • government policies • avoidance from long-term involvement • In Ethiopia, there is no HRH strategic plan, but there are explicit government policies in relation to HEW, health officers, emergency surgery • In Mozambique, a costed HRH plan (2008-2015) • In Liberia, emergency plan to produce more health workers

  28. Main issues in investing in HRH • Shortage of firm data to track aid flows to HRH • Spending on HRH is low, very little aid is provided to HRH • Fundamental disconnect -HRH is a bottleneck to scale up, but very little investment!! • In-service training gets the largest share, donors are almost absent in employing current labour force and pre-service training • Long-term investment vs sustainability • Concerns about management capacities • Concerns about capacity to influence the aid flows Source: Efficiency and effectiveness of aid flows for health workforce development. HRH Observer Issue No 7. WHO, January 2011

  29. The Paris Declaration: an accountability framework

  30. Improving fiscal space • Economic growth • Expanding external (donor) resources • Revenue generation • Public spending shift towards HRH • Public health care spending shift towards HRH Increase in the pie for health expenditure Increase in the HRH slice

  31. Remarks • To argue for scaling up health work force needs to consider: • How much it will cost to scale up health workforce • How much that scaling up will mean in terms of the current budget • What is the likelihood that this will increase performance • How much the increase is consistent with budgets • How you can increase administrative efficiencies • How you can mobilize additional resources

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