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Essential HRH Elements in Funding Proposals  

August 3-12, 2009

This discussion explored the opinions and perspectives of the HRH Exchange Community of Practice to determine what are the basic questions that should be asked with respect to HRH (human resources for health) interventions within a proposal or application. From these evidence-based and experiential contributions, a checklist of the essential HRH elements in funding proposals will be created.  

Discussion Statistics

Number of participants: 303
Number of participants' countries: 63
Number of contributions: 23
% of contributions from developing countries: About 64%
Number of countries contributing: 41 countries

Contributing countries: Belgium, Canada, India, Japan, Malawi, Nigeria, Peru, Swaziland, Uganda, USA, Vietnam

Purpose and Objectives


Discussion seeks to gather the opinions and perspectives of its Community of Practice to determine what are the basic questions that should be asked with respect to HRH (human resources for health) interventions within a proposal or application. From these evidence-based and experiential contributions, a checklist of the essential HRH elements in funding proposals will be created.


    To contribute to strengthening the HRH component of funding proposals or applications to a funding agency such as the Global Fund and PEPFAR and to review their processes Outline how a country-developed programme or application should be grounded in a well-developed, reasoned and evidence-based proposal that contributes to national human resource for health priorities.                                                          

  • Days 1-4: Considering the HRH crisis and from existing evidence and tools, what elements should be included in a country grant application?
  • Days 5-8: From discussions in Part I, what are the basic HRH questions that a reviewer or review team should ask prior to allocating funding awards?                                                                 
Emerging issue 1: Need for overall health systems strengthening (not only disease-specific support), continuity of programme

  • "The requests for funds for scaling up the workforce should also include matching proposals for making the current workforce more efficient. Human resources provision, its productivity and efficiency also depend on the form in which the systems and services of health are organized, appropriate infrastructure, equipment and the existence of standards and procedures for the provision of health services. I have observed that, in the services of health, where these conditions exist, the workers have a greater productivity and efficiency."
  • "In short, what I am saying is that, as we focus our energy on scaling up HRH to combat conditions like HIV/AIDS and TB, one should not lose sight of the issue of strengthening regulatory bodies in terms of capacity, resources and infrastructure."                                                                           
Emerging Issue 2: Training and incentives development

  • "…hopefully the proposal will support an incentive scheme to attract health workers to and retain them in rural and other hardship areas if such a scheme is not already being adequately funded, and proposal sections on scaling up health worker pre-service education would address how, through targeted recruitment from rural areas and underserved populations, curriculum reform, and other means, the training will contribute to health workers [becoming] more likely to serve in rural and other hardship areas."  
  • "Presence of health workers with skills not suited for health needs of their countries or communities (skill mix). For both doctors and nurses, African countries have largely focused on clinical training (which greatly needs scale-up) and specialties, rather than on the more relevant public health training. Example of doctors in the Philippines retraining themselves as nurses to pursue lucrative opportunities in a changing export market."                                    

Emerging Issue 3: Effects of funding on various cadres of health workers

  • "In Uganda, we have about 20 vertical AIDS care and/or research projects in Kampala alone, and these employ over 100 young, vibrant medical officers to do HIV/AIDS work alone. This is a big relief to the sector, where most of the graduates are on the street due to either inefficiency or impoverishment of the public service in absorbing the graduates. I am still clamouring for a proposal that can seek funding that can put the health worker into the overall health system where AIDS, malaria, TB and other conditions are handled."
  • •    "Usually in many Asian countries, those local health professionals who have 'power and big voice' tend to work in disease control, and not for those who work for health system strengthening (HSS) including HRH. This power structure is important. A few months ago I attended a WHO/WPRO meeting on PHC and HSS and discussed whether we need another cadre who should specialize in HSS including HRH, just like TB or malaria specialists, in each country to strengthen health systems. The response was not positive." 

Emerging Issue 4: Accountability, monitoring and evaluation
  • "Let the truth be told, of the whole money pumped into Africa from these fund nothing has been achieved. We should forget all these computer-generated figures just to deceive the world that something is happening.  The GFTAM as presently constituted and structured is only designed to favour the privileged few. What that is granted is not reaching the grass roots. However, what Africa need most is the basic primary health care workforce/centre at least within 5-minutes’ walking distance. The institution producing this work force should be established and strengthened. At the same time the whole population should be mobilised. Finally, the time has come that we have to audit the activities of the GFTAM and its recipients."                                                           
Emerging Issue 5: Equity and gender

  • Underpinning all of this is gender equity. In Mozambique for instance, medical students―mostly male―receive a good part of their training in English, which allows them professional and economic advantages not only due to their profession but also the access that English proficiency affords them. However, nurses―mostly women―comprise the majority of health workers there, as well as in numerous other African countries. They receive their training in Portuguese only---with the exception of the few dozen who are able to attain a BSN degree and receive a large part of their education in English. Furthermore, the discrepancy in pay between what a nurse earns and what a doctor earns is disgraceful." Dawn Surratt 

Programme examples

  • "Health workers themselves have unique insight into, among other HRH-related issues, what incentives and policies will most likely retain them and their peers in-country and attract and retain them to rural areas. In Ondo State, Nigeria, the proportion of nurses in rural areas increased from 28% to 66%, in part because the state government surveyed nurses as to their needs; they highlighted adequate supplies of equipment, and the government responded”. 
  • "From my experiences working with them in rural Cambodia and in Viet Nam for HIV care and treatment in the past, I do believe those health care workers deserve incentive for their professional work, in addition to what the government could pay at that time, to cope with ever-increasing workload to care and treat HIV patients. And I eventually saw that small scale incentive ($50-$60 per month) makes much difference in their work performance and retention". 

Additional important points

  • Agreement regarding an essential proposal checklist is key

Related activities and next steps

  • Agencies such as PEPFAR and the Global Fund will soon be reviewing submissions, and we hope that this discussion can assist both country submitters and the review teams.
  • The technical review of Round 9 applications to the GFATM (23 August-4 September). 
  • The technical reviews of 2010-11 programming in PEPFAR's 15 Focus Countries (with specific actions to meet the target to “train and retain” 140,000 health workers).

Post-forum survey results

  • Not available

References and resources
1.    General Policy Guidance for All Bilateral Programs 
2.    DRAFT Guidance for PEPFAR Partnership Frameworks and Partnership
Framework Implementation Plans - Version 1

1.    Toolkit for monitoring health systems strengthening.
2.    Task Force on Education and Training.
3.    Products of the Task Force on Human Resources for Health Financing.

Physicians for Human Rights
1.    Guide to Using Round 9 of the Global Fund to Fight AIDS, Tuberculosis and
Malaria to Support Health Systems Strengthening, October 2008. Updated from
March 2007 Guide developed for Round 7.
2. Global Fund Round 9 Opportunity to Build Human Resource Management
Capacity: the central pillar in health systems strengthening initiatives.
3. Strategies to implement health workforce and related provisions in the PEPFAR
reauthorization legislation (PL 110-293). February 2009

Global Fund
1. The Revised Guidelines on the Purpose, Structure and Composition of Country
Coordinating Mechanisms and Requirements for Grant Eligibility.
2. Technical Assistance and Other Guidance

Organizing groups

HRH Exchange, Global Health Workforce Alliance, World Health Organization, and Implementing Best Practices (IBP) Consortium

Contributing experts/facilitators 

  • James Buchan, Queen Margaret University, United Kingdom 
  • James Campbell, ICS INTEGRARE, Spain
  • Brad Corner, USAID, Ethiopia
  • Eric A. Friedman, Physicians for Human Rights, USA 
  • Donald Harbick, Management Sciences for Health(MSH) Leadership, Management and Sustainability (LMS) Projects, Nigeria 
  • Masamine Jimba, Department of Community & Global Health. Graduate School of Medicine, University of Tokyo, Japan
  • Dyness Kasungami, DFID, United Kingdom 
  • Tim Martineau, International Health Group, Liverpool School of Tropical Medicine, United Kingdom 
  • Zoë Mullan, The Lancet, United Kingdom
  • Judith Olton, ICS INTEGRARE, Switzerland                                               
Other acknowledgements

Katie Richey and Maggie Usher Patel, WHO/IBP Initiative provided support


Jeannelle Bernard, Research Officer, Global Health Workforce Alliance, supported by Mr. James Campbell, ICS INTEGRARE