Report of the Technical Working Group on

1. WILL WE ACHIEVE UNIVERSAL ACCESS TO HIV/AIDS SERVICES WITH THE HEALTH WORKFORCE WE HAVE? A SNAPSHOT FROM FIVE COUNTRIES Report of the Technical Working Group on Human Resources for Health (HRH) and Universal Access (UA) Global Health Workforce Alliance (GHWA) Dr Thomas Kenyon, Country Director, PEPFAR/CDC-Ethiopia

2. Composition of the GHWA technical working group on HRH and universal access • Mark Stirling, UNAIDS – co chair • Tom Kenyon, PEPFAR/CDC – co chair • Estelle Quain – PEPFAR/USAID • Karl-Lorenz Dehne and Jantine Jacobi, UNAIDS • Jim McCaffery and Wilma Gormley – Capacity Project (Secretariat) • Joan Holloway – PEPFAR/OGAC • Badara Samb – WHO • Sonia Diaz-Monsalve and Erica Wheeler – GHWA

3. Background • GHWA commissioned Task Force to examine interactions between efforts to reach universal access to HIV services and efforts to address the HRH crisis • TWG emerged to complete this work in four phases • Literature review • Protocol development for common rapid situational analysis across countries • Rapid situational analysis conducted in five countries • Final report and dissemination of results and follow on actions http://www.who.int/workforcealliance/about/taskforces/access/en/index.html

4. Countries with a critical shortage of health service providers (doctors, nurses and midwives) Thailand Ethiopia Cote d’Ivoire Zambia Mozambique Source: McCoy et al.Human Resources for Health 2008 6:16   doi:10.1186/1478-4491-6-16

5. Rapid situational analysisobjectives • Identify and document country-specific gaps and obstacles, which impede HRH scale-up for universal access • Identify and document country-specific promising mechanisms and practices that promote scale-up towards universal access and enhance the health system in general • Develop practical and actionable guidance for countries, including policy considerations, to further scale-up HRH for universal access and strengthen the health system in general • Initiate a sustained process to ultimately catalyze and enhance the active engagement of in-country stakeholders to support scale-up towards universal access and health systems improvement through strengthening HRH

6. Key elements of country analysis • 2-3 member team spent 10 days in country collecting information and writing report • Supported by WHO national office and a national level Steering Group • Collected available information • HIV epidemiology and program indicators • Strength of health workforce • National HRH plans/strategies • Status of task shifting and training

7. Major questions posed to key informants • What promising practices exist that are having a positive impact on scale up on universal access? • What are the HRH gaps and challenges that specifically relate to the country’s goals/targets for HIV/AIDS? • What are the most critical interventions that will address challenges and lead to effective scale up? • What leadership action and partner support is required to enable implementation of HRH scale up?

8. HIV , universal access, and HRH indicators

9. Major findings Promising practices • Countries have 5-10 year HRH Strategic Plans • Production of new health workers is increasing • Pilot efforts underway to increase retention and improve work force distribution • Task shifting used to support decentralization and increase access • Efforts to scale-up community responses are underway • HIV services are being integrated into mainstream service delivery

10. The extrapolation of the professional staffs to deliver ART services, Thailand 2008 - 2015 Total Nurse Doctors Conselor Source: Ministry of Public Health, Thailand

11. Examples of increased production • Ethiopia • 30,000 Health Extension Workers for PHC and MDGs • 9,000 Health Information Technicians for HMIS • From 683 health officers in 2004 to 1600 in 2009 • Increasing medical student intake to 8,000 per yr • Mozambique • Increasing workforce by 79% by 2015 • Doctors, nurses, skilled birth attendants emphasized • Thailand • 60 year history of building an appropriate workforce • Have reached ratio of 4 health workers/1000 population

12. Workforce projections, Mozambique, 2006-2015

13. Thailand Health Facilities 9,762 rural health centres, 730 community hospitals, 150 big public hospital Total public beds 141,451. 344 private hospitals, 35,806 beds (20.2 %) 16,800 private clinics, 14,000 drug stores Health Manpower 30,000 MDs, 120,000 nurses, 10,000 dentists, 10,000 pharmacists, 40,000 CHWs, mainly produced by public institutes National Health Expenditure From 3.82% GDP in 1980 to 6.1 % in 2005 2007 • Population of 65 million • GDP/capita of 3,050 $US • Life expectancy 73.5 years • The top causes of burden of diseases are unsafe sex, alcohol and tobacco consumption, and hypertension Source: Ministry of Public Health, Thailand

14. Examples of steps taken to improve retention • Thailand • Salary incentive offered to serve in rural areas • Zambia • HIV/AIDS services for health workers themselves • Rural retention scheme • Ethiopia • Beginning private ward and fee retention schemes • Various incentives being offered to work in rural areas • Cote d’Ivoire • Salary incentive offered to work in embattled north • Mozambique • 14% of HRH budget planned for retention incentives

15. Status of task-shifting in countries • Widely practiced and improving access • HIV counseling and rapid testing – all but Thailand • Perform male circumcision – Ethiopia, Zambia • Order CD4 tests – all countries • Provide ARVs to pregnant women – all countries • Initiation of ART by clinicians other than doctors – all but Cote d’Ivoire and Thailand • ART refills in stable patients – all countries • Provide ARVs for PEP – all countries • Prescribe OI drugs – all but Thailand

16. Major findingsGaps and challenges • Many country HRH scale-up efforts remain unfunded and delayed in implementation • HR management systems extremely weak • Insufficient attention has been given to HRH as a health systems component for reaching universal access • Estimated workforce needs have not been calculated • Scaling up production is costly and time-consuming • Shortage of tutors and instructors is problematic • Formal policies on tasking shifting are lacking • Over-reliance on HIV in-service training rather than integration of HIV into pre-service curricula • Little attention being given to a HIV prevention workforce

17. Roles of a prevention workforce Preventing Sexual Transmission • Behavior change programs (to increase condom use, delay initiation of sexual behavior in young people, and reduce the number of partners) • Condom promotion • HIV testing • Diagnosis and treatment of sexually transmitted infections • Adult male circumcision Preventing blood borne transmission • Provision of clean injection equipment to injection drug users • Methadone or other substitution therapy for drug dependence • Blood safety (including routine screening of donated blood) • Infection control in health care settings (including injection safety, universal precautions, and antiretroviral prophylaxis following potential HIV exposure) Preventing mother-to-child transmission • Primary HIV prevention for women of childbearing age • Antiretroviral drugs • Prevention of unintended pregnancy in HIV-positive women • Breastfeeding alternatives • Caesarean delivery (in the case of high maternal viral load) Source: http://www.globalhivprevention.org/pdfs/pwg_access_factsheet_6_07.pdf

18. Limitations of country snapshots • Data on human resources is lacking • Specific workforce issues that could not be addressed in-depth: • HIV prevention activities • Pediatric HIV/AIDS services • Strategic information and public health workers • Effect of HIV/AIDS on health workers themselves • Contribution of the private sector workforce • Capacity of pre-service training institutions • Workforce issues outside health institutions

19. TWG conclusions • Countries visited are making substantial progress towards universal access and integration of HIV • Workforce innovations, including task-shifting, are contributing to that success • The projected workforce is a major obstacle to reach and maintain universal access amidst a growing HIV/AIDS epidemic • Existing National HRH plans represent an important opportunity for country leadership and development partners to expand the workforce in support of universal access, HIV integration, and meeting other Millennium Development Goals

20. Critical interventions needed at country level (based on country cases) • Move from costed HRH strategic plan to prioritized implementation, addressing both HIV and other health service needs • Estimate HR requirements for universal access and scale up HRH production, making certain pre-service curricula includes appropriate HIV/AIDS content • Continue working on task shifting and building community health worker cadres including involvement of PLHA • Address HRH retention and distribution to hard to reach populations and areas • Strengthen HW performance (low motivation and job satisfaction), includes work place safety programs • Strengthen Human Resources Management Systems

21. Acknowledgments Cote d’Ivoire Team Mozambique Team Ms. Wanda Jaskiewicz, IntraHealth International Dr. Maria Ines Tomo, World Health Organization Dr. Francisco Langa, Ministry of Health Dr. Hilde de Graeve, World Health Organization Dr. Catherine McKinney, CDC Dr. Lucy Ramirez, CDC Thidaporn Jirawattanapisal, Ministry of Public Health Sombat Thanprasertsuk, WHO Thinakorn Noree, Inter-HRH • Dr. Virginie Ettiegne-Traore, Ministry of Health, Director, PNPEC • Mr. Dick Wall, Capacity Plus Project consultant • Dr. Juma Kariburyo, HIV Administrator, WHO Cote d’Ivoire • Dr. Abo Kouame, Senior Technical Advisor, PNPEC • Samrawit Nigussie, Ministry of Health • Dr. Gebrekidane Mesfin, WHO Ethiopia • Dr. Degu Jerene, WHO Ethiopia • Dr. Gijs Elzinga, Capacity Plus Project consultant • Susan Tembo-Ziomba, WHO Zambia • Isaac Kakumbi, Ministry of Health • Dr. Gijs Elzinga, Capacity Plus Project consultant Ethiopia Team Thailand Team Zambia Team

22. On behalf of the Global Health Workforce Alliance TWG on HRH and Universal AccessTHANK YOU!