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
Purpose:
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.
Objective:
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.
Themes
- 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
References and resources
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
Moderators
Jeannelle Bernard, Research Officer, Global Health Workforce
Alliance, supported by Mr. James Campbell, ICS INTEGRARE
