Lessons For Developing Winning GF Proposals To Support Human Resource Strengthening The Health Systems Strengthening through the AAAH Global Fund Round 7 Workshop 8-10 May 2007 Anne Martin-Staple PhD President and Chief Economist Health Strategies International LLC

WHO, Global Health Atlas Introduction –Round 5: Malawi Supported resource shortfall (US$65.4m) for Six-Year HR Emergency Plan and HIV/AIDS HR Model –Round 6: Zambia proposal to support Health Sector HR Planning and Finance Model and Malaria Scale-up HR Model

Key points for winning proposals WINNING THEME: GF should strengthen NOT weaken public and civil society health sector 1. Include health system strengthening 2. Technically sound and quantified 3. Link HR activities to disease goals 4. Provide comprehensive strategies 5. Resource envelop, gaps and cost sharing

STEPS TO WINNING PROPOSALS 1. Assess health sector workforce shortfall 2. Assess staffing requirements and shortfall for disease- specific interventions i.e. HIV/AIDS/ART, malaria 3. Analyzing labor market issues 4. Develop a mix of integrated, costed strategies to meet HR shortfall 5. Mobilize political commitment and resources to meet HR targets 6. Develop operational plans to implement recruitment, retention and training strategies

WHO, Global Health Atlas STEP 1: Critical HR Shortfall

STEP 2: HR Crisis Threatens disease-specific programs Rapid expansion of programs (HIV/AIDS, EHP, TB, Malaria, ART) with no proportional expansion of workforce puts critical drain on health sectors Rapid expansion of programs (HIV/AIDS, EHP, TB, Malaria, ART) with no proportional expansion of workforce puts critical drain on health sectors HR crisis threatens effective scale-up of disease specific programs especially in rural areas HR crisis threatens effective scale-up of disease specific programs especially in rural areas HR crisis threaten sustainability of programs HR crisis threaten sustainability of programs

WHO, Global Health Atlas HIV/AIDS driving HR demand

WHO, Global Health Atlas The 6-Year Plan Gap that tied the proposal to HIV/AIDS services Health Surveillance assistants (HSAs) (4200 including 1000 PWAs) Other cadres: doctors, nurses, COs, counselors Tutor career development Training institution support

Zambia: Ensuring malaria scale-up in context of overall MoH HR Goal: To determine the level of public sector and civil service HR effort required to carry out effective malaria scale-up and associated financial costs Develop a HR Finance Model with a mix of costed strategies to meet MoH workforce targets in 4-years Develop malaria specific HR Finance Model to determine staffing LOE and cost for scale-up Promote increased role of private sector (e.g. CHAZ) and civil society for malaria scale-up

WHO, Global Health Atlas STEP 3: Analyzing Labor Market Issues 1.Poor retention of existing staff 2.Inadequate trained labour supply 3.Inequitable staffing distribution

WHO, Global Health Atlas Push Factors Poor pay and benefits Poor working conditions Delayed payment Lack of incentive schemes/career development Personal security Poor supervision and management Poor HR infrastructure Poor living conditions: housing High transport costs

WHO, Global Health Atlas Pull Factor: Brain Drain To countries with greater financial rewards, improved working conditions, opportunities for further training To private sector NGO and research projects

WHO, Global Health Atlas Inadequate Trained Labor Supply Training institutions have inadequate output Due to the lack of qualified health workers, recruitment outside of the country is required

WHO, Global Health Atlas Inequitable distribution 97% and 94% of COs and RNs in urban areas High vacancies at under-served rural areas 10 districts without a MOH doctor 4 districts have no doctor 6 districts have nursing vacancies over 70%

WHO, Global Health Atlas STEP 4: Defining costed strategies for meeting HR targets 1.Determine HR shortfall and targets by cadre 2.Estimate the cost of mix of synergetic strategies 3.Develop HR finance model 4.Examine finance implications: 5.Determine resource envelop 6.Estimate resource mobilisation targets

WHO, Global Health Atlas Training Institution Cadre Current Enrollment Required Capacity Expansion College of Medicine Physicians Kammuzu School of Nursing & CHA of Malawi Nurses Malawi College of Helath Sciences Technicians

WHO, Global Health Atlas Training: Estimating the costs of Expanding Institutional Capacity –Capital costs for classrooms, dormitories, and labs –Salary costs for newly hired tutors and staff –Staff recruitment and training costs (overseas PhD programs) –Increase in operating costs as enrolment expands $63 million estimated over 6 years

WHO, Global Health Atlas OUTPUTS FROM BUILDING TRAINING CAPACITY

WHO, Global Health Atlas STEP 5: Finances Mobilized Six-Year Emergency HR Programme Total programme cost = US$272 million US$210M = Recruitment and retention US$62 M = Training Capacity Donor financing – US$182M Gap = US$90M Requested = US$65.4M

WHO, Global Health Atlas Staff retention improves “The number of resignation letters from nurses has reduced from six per month to almost none” “Before the remuneration supplement in April, we were having more than 120 nurses going to the UK,”….. Although they are working in harsh conditions, we have seen the improvements in their morale.” Malawi Health Minister Hetherwick Ntaba, January 2006

WHO, Global Health Atlas Thank you Dr. Anne Martin-Staple President, Health Strategies International