TRP identifies gaps in human resources for health interventions in funding requests to the Global Fund

9. NEWS
28 Jan 2019
Often, large requests for HRH initiatives were made at the expense of other essential RSSH investments, TRP says

“Many funding requests do not acknowledge or address the common problem of shortage or maldistribution of human resources for health (HRH),” the Technical Review Panel (TRP) says. “Some funding requests did not mention HRH challenges nor the risks these pose to meeting service delivery targets.”

The TRP made these comments in a report it released recently on RSSH investments in the 2017–2019 allocation period. The report contained a section on HRH. This article summarizes the TRP’s findings with respect to HRH-related gaps in funding requests as well as the TRP’s recommendations on how applicants, the Global Fund and partners can address these gaps.

(See our article on the full report in GFO 348; and our article on the section of the report on integrated service delivery elsewhere in this issue.)

For its report, the TRP analyzed 50 funding requests from Windows 1–5.

The TRP noted that an estimated 80% of HRH investments went towards salaries and other remuneration.

Some HRH requests were not aligned with Global Fund HRH guidance and did not demonstrate value for money, the TRP observed. Often, large requests for HRH investments were made at the expense of other essential RSSH investments.

Incentive schemes for government workers are often inconsistent within countries, the TRP noted. In addition, it said, there is no standard salary scale among donors for community health workers (CHWs).

The TRP said that requests for HRH and CHW expansion are not often supported by findings from an HRH needs assessment or strategy, showing how expansion fits within the overall national HRH gap analysis or strategy. “It was challenging … to assess strategic focus and technical soundness in funding requests that were not based on [a] quantitative or qualitative HRH gaps analysis,” the TRP stated.

The TRP noted a continued reliance on expensive traditional training methods –– i.e. classroom-based trainings and workshops –– as opposed to e-technology, which, it said, is more efficient. As well, the TRP said, there is a greater reliance on in-service training as opposed to pre-service training, “which is an inefficient use of resources and results in the absence of staff from health care facilities during the training.”

The TRP said there was no evidence in the funding requests that countries facing HRH shortages will develop multi-skilled workers or multi-disciplinary teams able to provide comprehensive services. There were few examples in funding requests of the use of task shifting and other HRH efficiency enhancing measures, the TRP stated. As an illustration of the problem, it said, one funding request called for the use of nurses and doctors to do TB contact tracing, rather than relying on people in the community for this function.

There a common tendency for funding requests to propose a rapid expansion of the use of CHWs, the TRP stated, without including an appropriate budget and without referencing all of the supporting systems required to ensure the effectiveness, sustainability and value for money of deploying CHWs.

The TRP said that “a positive example of CHW extension is Ethiopia’s health extension worker (HEW) model, which integrates community health workers into the primary health care system, promotes regular interaction with clinics and allows for a career path for the community health worker.”

The TRP noted that it was uncommon to see initiatives in funding requests to transition CHW and health staff from Global Fund support to domestic funding. “While CHWs are very important for service delivery, countries still need a vision and strategy for HRH development and gradual absorption of CHWs into the formal health service,” the TRP commented.

Finally, the TRP observed, most funding requests do not explicitly address gender issues arising in the selection, deployment and support of the health workforce –– issues such as gender-power relationships and dynamics between health providers and clients, and within the health workforce itself, which may undermine coverage and quality of care.

TRP recommendations

  • The Secretariat should revise its HRH Framework to require countries to consider HRH investments in relation to the 4S development continuum. (See the description of the 4S model in a separate GFO article on the full TRP report.)
  • Applicants should request funding for an HRH needs assessment and the development of a “human resources for health” plan (or refer to these documents in the funding request if they already exist). The human resources for health plan should describe interventions to fill gaps in the health workforce; strategies to ensure the retention of health workers; and policies on community health volunteers.
  • Applicants should conduct evaluations such as service availability and readiness assessments (SARA) or workload indicator of staffing needs (WISN) to assess the existing workload and the country’s ability to absorb additional functions as a consequence of integration of services.
  • Applicants should base their funding requests on strategic HRH activities in the national HRH plan or equivalent. Applicants should clarify how government funding and other donors are addressing critical HRH challenges.
  • Where the Global Fund is investing in salaries, a clear plan for transitioning that support to national budgets should be included in the funding request along with a documented commitment of the national government.
  • Applicants should pay more attention in their funding requests to HRH quality and the efficient use of the existing workforce. Training requests should prioritize improving pre-service training and increased use of e-technology.
  • Countries and donor partners should adopt a common HRH compensation framework to avoid significant differences in remuneration between government and non-government service providers for the same work.
  • Applicants should prioritize investments to improve the effectiveness and sustainability of CHWs. CHWs should be supported over the long term, preferably through absorption into the formal health system. Early takeover of recurring costs by government is essential even if it means doing so incrementally over time.

 

 


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