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GFO Issue 44



Eric A. Friedman

Article Type:

Article Number: 2

ABSTRACT A new report discusses circumstances in which Round 5 proposals to the Global Fund can specify that some of the grant will be used to pay salaries of health system workers.

The shortage of health workers in Africa has become recognized as the most significant constraint to scaling up health services, including for AIDS, tuberculosis, and malaria. Countries outside Africa also face significant health workforce challenges. Meeting health workforce needs will require significant funds. The Global Fund is one important possible source for the financial resources required to support human resources. Physicians for Human Rights has produced a guide on situations in which Global Fund grants can be used to help pay for human resources for health. [See]

The Global Fund accepts Round 5 proposals for health systems development, including human resources for health (HRH), provided that the proposals demonstrate that such activities are “necessary prerequisites to improving coverage in the fight against any or all of the three diseases.” This is fundamental. The stronger the connection between a strengthened health system and fighting at least one of the diseases that can be made, the more favorably the Technical Review Panel (TRP) can be expected to view the proposal. This must be done, in part, by including at least three disease-relevant indicators for these activities. If countries can demonstrate the required connection, they can receive support from the Global Fund for a wide range of HRH activities. Furthermore, the Global Fund is willing to support health workers who spend part of their time on activities unrelated to the three diseases.

Several countries have demonstrated how the Global Fund can support large-scale HRH interventions. Zambia, for example, will receive funding through its Round 4 HIV/AIDS proposal to provide incentives to hire more than 5,000 health workers who will contribute to Zambia’s anti-retroviral therapy program. These workers will also provide other health services.

Zambia’s careful balancing act between AIDS and non-AIDS activities is notable. The health workers included in the incentive scheme are not limited to HIV/AIDS activities. Yet by limiting the incentive scheme to health workers providing anti-retroviral therapy, Zambia did not extend its funding request so far beyond the three diseases that the TRP might have found the connection with AIDS to be unacceptably weak.

Rwanda’s successful third round HIV/AIDS proposal took a similar approach with respect to salaries. The grant is paying salaries to new health staff who work at the health facilities that are the focus of the HIV/AIDS care system in Rwanda, and perform both HIV/AIDS and non-HIV/AIDS health services.

Swaziland has made perhaps the most innovative use of the Global Fund’s HRH support by successfully applying for compensation of US$350 per year to community members who care for orphans and vulnerable children. The compensation will ultimately reach members of 360 communities.

Zambia, Rwanda, and Swaziland represent exceptions. Most countries have not applied for significant Global Fund assistance in the area of salaries and incentives. Another area where the Global Fund has been underutilized is health worker safety, such as the provision of universal precautions, post exposure prophylaxis, and health workplace HIV prevention programs. Since these are direct HIV prevention interventions, countries require no special justification for them. At the same time, surveys find that poor working conditions are one of the top reasons that health professionals emigrate. These interventions, therefore, are critical to retaining health workers.

In another crucial area, HRH management and planning, the Global Fund support has been largely for supervision, though many other interventions are possible. Better HRH management is one of the key elements of retaining health professionals. If countries can demonstrate that these interventions are required to increase coverage in the fight against AIDS, tuberculosis, and/or malaria, whether by improving health worker retention or by improving the effectiveness of health workers providing services in the three disease areas, the Global Fund will consider funding them.

Two types of HRH-related proposals warrant caution. First are those that are so ambitious that the TRP may view them as general health systems funding, outside the mandate of a mechanism designed to combat three particular diseases. Second, the TRP has expressed skepticism about the Global Fund’s role in longer term health systems development, particular if it will not have immediate impact. This calls into question the extent to which the Global Fund will support the education of new health workers, especially professionals who require lengthy training, even though it did so in one Round 1 grant. Such investments may well be required to achieve and sustain long-term high coverage for the three diseases, yet may lack immediate impact. In light of this tension, a strategy that countries might want to follow is to apply to the Global Fund to fill relatively small but critical gaps in the health education system, but not use the Global Fund as the major mechanism for meeting HRH production requirements.

Because of the relatively few proposals with significant HRH components that countries have submitted, some uncertainty remains as to exactly what the TRP will approve. At the same time, there is no doubt as to the extent of the HRH crisis in many countries. Applicants will have to make their own judgments as to the degree of risk they are willing to take. As several successful proposals have demonstrated, the Global Fund does have real potential in playing a meaningful role in alleviating HRH crises, and countries are urged to make use of this potential.

[Eric A. Friedman ( is HIV/AIDS Policy Analyst for Physicians for Human Rights. His full report, Guidance to the Global Fund and Support for Human Resources for Health, is accessible at]

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