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Making Health Workers Count

The Global Health Workforce Alliance 2012 Annual Report

This report was produced by the Global Health Workforce Alliance (the Alliance). The Alliance is hosted by the World Health Organization. All rea-sonable precautions have been taken by the Alliance to verify the informa-tion contained in this publication. Notwithstanding, the Secretariat of the Alliance welcomes any comments, suggestions and notification of errors or inconsistencies, which can be submitted to [email protected]. The respon-sibility for the interpretation and use of the material lies with the reader.

Requests for permission to reproduce or translate this publication – whether for sale or for non-commercial distribution – should be addressed to [email protected].

The extracts of the voices of health workers are taken with kind permis-sion from the United States Agency for International Development (USAID) funded CapacityPlus, led by Alliance partner IntraHealth International (full details are available in the ‘I’m a health worker’ section of the website http://www.capacityplus.org/imahealthworker).

Photo credits

> Cover: © Marco Dormino> Page 6: Masato Mugitani > Page 6: Mubashar Sheikh / © GHWA / Eric Williams> Page 7, 23, 28: Verah Nkosi, Louise Walusimbi, Fatiya Askederin,

Rosa Lara de Forel / © Mesrak Belatchew / IntraHealth International> Page 10 and 11: © WHO / © WHO / Adèle Marie /

© GHWA / OnAsia / L. Duggleby> Page 13: © Guilio Di Sturco> 5: © Jenny Matthews/ Merlin> Page 35, 39, 45: © Edward Echwalu /

www.echwaluphotography.wordpress.com

6 MessagefromtheChairandExecutiveDirector

8 Introduction8 A growing momentum for universal health coverage

10 Keymilestones2006-2012

12 Advocatingforhealthworkerstobeattheheartoftheglobalhealthagenda12 Shifts in global disease burden

12 The post-2015 development agenda

13 Integrating human resources for health into key policy processes

16 Regional networks for HRH policy dialogue strengthened

19 Corporate communications

24 Facilitatingcountryactions26 Improving the policy environment for HRH development

30 Country progress in developing and implementing health

workforce strategies through CCF

31 Master’s programme in HRH management for

francophone countries

32 Assessments and country profiles

34 Promotingevidence-basedHRHsolutions34 Policy dialogue on HRH labour markets in Africa facilitated

34 Assisting countries to develop human resources for

health plans and assess impact

36 The role of the private sector in HRH development

37 Monitoring human resources for health interventions

38 ManagementandGoverningbodies38 External evaluation

38 The new Alliance strategy for 2013-2016

39 The Alliance Secretariat: value for money and cost effectiveness

39 Membership and partnerships

40 Budget and finance

44 Lookingforward

http://www.capacityplus.org/imahealthworker

List of figures, boxes and tables

Figure 1: Website unique users and monthly visits from 2009-2012Figure 2: Countries authorizing community health workers to diagnose and treat pneumoniaFigure 3: Progress in tackling human resources for health shortages in priority countriesFigure 4: Six steps in the country coordination and facilitation approachFigure 5: Results of Alliance support to 24 countries (2009-2012)

Box 1: Alliance achievements during 2006-2012Box 2: Sensitizing political leadership on HRH through advocacy eventsBox 3: The Health Workforce Advocacy InitiativeBox 4: Improving health services at the community levelBox 5: How the Alliance promotes country actions through its members and partnersBox 6: HRH development in Africa to improve maternal and child health (Muskoka Project)Box 7: How effective are mid-level health workers? The results of the Alliance’s analysisBox 8: Three core objectives of the Alliances’ strategy for 2103-2106Box 9: Key results for 2013 contributing to the Alliance’s vision

Table 1: Annual Financial Statement of the Alliance as of 31 December 2012 Table 2: Funding contribution to the Alliance from 2006 to 2012 (December)

Acronyms and abbreviations

AAAH Asian-Pacific Action Alliance for Human Resources for HealthADB African Development BankAFD Agence Française de Développement (French Development Agency)AIDS Acquired immunodeficiency syndromeAPHA African Public Health AllianceAPHRH African Platform for Human Resources for Health AU African UnionBMZ/GIZ German Federal Ministry for Economic Cooperation and Development/Gesellschaft für Internationale Zusammenarbeit (German International Development Agency)CCF Country Coordination and Facilitation approachCHCP Community health care provider (Bangladesh)CHW Community health worker

CSO Civil society organizationDFID United Kingdom Department for International DevelopmentDORP Development Organization for the Rural Poor (Bangladeshi civil society organization)EQUINET European Network of Specialized National Equality BodiesEU European UnionGHWA Global Health Workforce AllianceGlobal Fund Global Fund to Fight AIDS, Tuberculosis and Malaria HAF Health Action FrameworkHHA Harmonization for Health in Africa HIV Human immunodeficiency virusHRH Human resources for healthHWAI Health Workforce Advocacy InitiativeIAPAE International Academy of Physician Associate Educators IT Information technologyKD-AGA Kampala Declaration and Agenda for Global Action MCH Maternal and child healthMDG Millennium Development Goal MLHP Mid-level health providerMNCH Maternal, newborn and child healthNCD Noncommunicable diseaseNGO Nongovernmental organizationNORAD Norwegian Agency for Development CooperationOECD Organisation for Economic Co-operation and Development ORS Oral rehydration saltsPAHO Pan-American Health OrganizationPIAT Policy impact assessment toolPSTF Private Sector Task Force ReportREC Regional Economic CommissionUHC Universal health coverageUN Women United Nations Entity for Gender Equality and the Empowerment of WomenUN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s FundUSAID United States Agency for International DevelopmentWB World Bank WHO World Health Organization WHPA World Health Professions Alliance

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Verah Nkosi did not always dream of becoming a health worker. But things changed as the 21-year-old student of nursing-midwifery underwent her train-ing “It wasn’t always my passion. The passion started growing in me – I started loving being a nurse.” Now in her final year at Kamuzu College of Nursing in Malawi, Nkosi is a young woman who has found her path in life. “It brings satisfaction in my heart that I am serving people and my country,” she says. Nkosi now plans to take a master’s degree in neonatology and child health and looks forward to being “a recognized member of the society working for the public sector.” For now, she says, “I have the internal feeling of happiness that I am doing something to help others.”

Malawi is striving to train more students to fill the health worker gaps in the country. The skills Nkosi is acquiring are in high demand, especially in rural and remote areas (the vacancy rate for nursing and mid-wifery positions in the public sector is 65 percent, and while 85 percent of the population lives in rural areas, only 29 percent of Malawi’s nursing professionals provide services there according to ministry of health data). However, while many of Nkosi’s class of 106 students will drop out as a result of pregnancy, sickness, or poor academic performance, many of those who do graduate will choose not to work in remote areas where the need is highest, as they prefer to be in or near the capital city in a well-resourced facility. Other challenges facing Malawi’s nursing and midwifery education system include a shortage of tutors at clinical sites, insufficient teaching equipment, and lack of classroom space.

This year has been a critical period of transition between the first five years of the Alliance and the introduction of the new strategy for 2013-2016, and a time to take stock of progress, and the new HRH landscapes and challenges. Despite signifi-cant success in addressing the HRH crisis, major challenges remain.

The new strategy has been developed around the Alliance’s leadership role in advocating for, and catalyzing actions to improve HRH, and contribute to the health-related MDGs and achieve universal health coverage. Greater collaboration, account-ability for results, and impact are needed, and the Alliance is the only global platform with the mandate and capacity to bring together all HRH stakeholders – both state and non-state – around a common agenda. The strength of the Alliance is its 460+ members, effectively (and cost-effectively) advocating at global, regional, and national levels to improve the performance of the health work-force. The strategy aims to fully harness the huge potential of the network and mobilize members to play a proactive role in support of national HRH development priorities.

The HRH agenda is a long-term one – requiring a clear vision and global consensus. The Alliance has contributed to a range of global, regional and national level initiatives to move the agenda forward. In 2012, substantive progress contin-ued with: increased investments, scaling-up of health worker education and retention initiatives, strengthened HRH coordination, improved govern-ance and planning in 24 countries (through the country coordination and facilitation principles), mainstreaming of HRH through over 20 interna-tional and national advocacy and policy dialogue processes and events and in political declarations and commitments, and development and dissemi-nation of unique products and tools to share good practices and information.

The Global Health Workforce Alliance (the Alliance) has played a catalytic role in responding to the severe global shortage of health workers. During its first five years from 2006–2011, the Alliance led a movement that focused worldwide attention on the human resources for health (HRH) crisis and mobilized action to increase recognition of health workers. Major progress has been made in many countries in response to the HRH challenges.

As plans for the post-2015 development agenda are discussed, the Alliance has a key role to play in ensuring that a contemporary HRH focus is advanced that will mobilize political will, catalyze action and lead to new commitments in strength-ening the health workforce and addressing HRH challenges. In 2013, a significant event, the Third Global Forum on HRH to be held in Brazil, will be instrumental in ensuring global consensus on HRH strategies and priorities in the post-2015 develop-ment agenda and for universal health coverage.

As we move forward, the Alliance will serve as a nucleus for a growing movement of advocates

Message from the Chair and Executive Director

DrMubasharSheikh – Executive DirectorGlobal Health Workforce Alliance

DrMasatoMugitani– Chair Assistant Minister for Global Health, Ministry of Health, Labour and Welfare, Japan

committed to positive change. The Alliance Board and the Secretariat would like to thank all of its partners, members and supporters, and its host, the World Health Organization, for their sustained support and engagement throughout 2012. We look forward to continuing and strengthened col-laboration in the coming years.

Dr Masato Mugitani, ChairDr Mubashar Sheikh, Executive Director

Global Health Workforce Alliance

Voices of health workers

Verah Nkosi

8 9

The HRH crisis is a global issue that impacts high-, middle- and low-income countries. The crisis can only be resolved – and health outcomes improved and lives saved – through the delivery of essential health services by an available, capable, moti-vated, and well-supported health workforce. HRH issues will be addressed at the Third Global Forum on Human Resources for Health to be held in Brazil in 2013, with the theme ‘Human resources for health: foundation for universal health coverage and the post-2015 development agenda’.

During 2012, progress can be shown through a number of key achievements, which are described in this report and include: > Endorsement by the Alliance Board and launch

of the new strategy for 2013-2016: Advancing the health workforce agenda within universal health coverage;

> Mainstreaming of HRH through over 20 inter-national and national advocacy and policy dialogue processes and events and in political declarations and commitments;

> Supporting 12 existing countries to strengthen their health workforce and develop and imple-ment HRH plans, and extending assistance to five additional countries;

> Improving coordination, leadership, and plan-ning through the country coordination and facilitation principles;

> Catalyzing governments to improve HRH coor-dination and management between govern-ment, the private sector, and civil society;

> Collaborating with and strengthening regional networks to enhance HRH coordination, exchange learning and best practices, and advance the HRH agenda;

> Developing and disseminating unique knowl-edge products and tools to share good prac-tices and information, utilizing e-learning, web technology, social media, and print;

The Global Health Workforce Alliance (the Alliance) was launched in 2006 as a response to the global human resources for health (HRH) crisis. Hun-dreds of millions of people around the world do not have access to quality health care and millions still die from preventable causes. This situation exists due to a chronic shortage of health workers, exacerbated by poor distribution, low motivation and retention, inadequate skills or training and poor working conditions. The Alliance envisions that “all people everywhere will have access to a skilled, motivated and supported health worker, within an effective robust health system”.

The Alliance is a global partnership of national governments, civil society, international agencies, financial institutions, educators and other stake-holders, hosted by the World Health Organization (WHO) in its headquarters in Geneva, Switzerland. The Alliance’s focus is on developing the health workforce under the framework of the Kampala Declaration and Agenda for Global Action (KD-AGA), adopted at the ‘First Global Forum on Human Resources for Health’ in Kampala, Uganda in 2008.

A growing momentum for universal health coverage

The Alliance is at the centre of a movement to improve health resources, advocating for HRH as the critical pathway, and catalyzing global and country actions towards universal health coverage (UHC) and the achievement of the health-related Millennium Development Goals (MDGs). Univer-sal health coverage (UHC) has emerged as a key framework in the post-2015 development agenda, culminating in the adoption of a United Nations General Assembly Resolution in December 2012. The resolution acknowledges the need for an “adequate skilled, well-trained and motivated workforce” to achieve universal coverage.

> Developing methodologies, analysis, tools and resources to document the HRH coordination, planning and development processes, and assess the effectiveness of Alliance support; and

> Planning for the ‘Third Global Forum on Human Resources for Health’ in Brazil, in 2013, to focus on integrating HRH in consultations on the post-2015 development framework.

Introduction

Allianceachievementsduring2006-2012 Box1

> Human resources for health (HRH) mainstreamed into the health policy and development discourse; > HRH-specific language and targets included in the UN Global Strategy for Women’s and Children’s Health;> Two Global Forums on HRH, organized in collaboration with Alliance members and partners;> Regional Alliance-supported conferences (e.g. Asia Pacific Action Alliance for Human Resources for Health

and African Platform on Human Resources for Health) provided a platform for policy dialogue among

countries;> Thematic task forces convened by the Alliance led to groundbreaking knowledge products on health

workforce development;> Collaborative platforms at national level strengthened through the Country Coordination and Facilitation

(CCF) approach;> Norway and Thailand spearheaded efforts for the development and adoption of the Global Code of

Practice on International Recruitment of Health Personnel in 2010;> Adoption of a resolution on the Global Code of Practice on the International Recruitment of Health

Personnel;> Members of the World Health Professions Alliance (WHPA) improved working conditions for health profes-

sionals through the Positive Practice Environment campaign;> The Governments of Japan, Italy and France led G8 commitments in 2008, 2009 and 2011 respectively, to

support HRH development;> A new resolution recognizing the “importance of frontline health workers towards accelerating progress

on global health” was introduced to the United States Congress in April 2012.

http://www.un.org/ga/search/viewm_doc.asp?symbol=A/67/L.36

http://www.un.org/ga/search/viewm_doc.asp?symbol=A/67/L.36

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Key milestones

Alliance history at a glance 2006 – 2012

20062007

200820 09

20102011

2012

April 2006Launch of World Health

Report 2006:

Working together for health

March 2008‘First Global Forum on Human

Resources for Health’, Kampala,

Tanzania and launch of the

Kampala Declaration and

Agenda for Global Action

May 2010World Health Assembly, Geneva, adopts the Global Code of

Practice on International Recruitment of Health Personnel.

Jannuary 2011‘Second Global Forum on Human Resources for Health’,

Bangkok, Thailand. Launch of the Progress report on

the Kampala Declaration and Agenda for Global Action.

May 2006Launch of the Alliance,

World Health Assembly,

Geneva

2009-2011Moving forward from Kampala strategic framework

(2009-2011) adopted. Launch of the Alliance’s

‘Country Coordination and Facilitation process’ (CCF).

December 2011External Evaluation of the Global

Health Workforce Alliance conducted.

June 2007Alliance organizes Human ‘Human

Resources for Health in Africa

conference’, Douala

July 2012Alliance Board endorses

new strategy for the

Alliance’s second phase,

covering the period

2013-2016:

Advancing the

health workforce

agenda within

universal health

coverage.

Advocating for health workers to be at the heart of the global health agenda

developing countries are still being educated and trained mainly to address the old case mix. Moreo-ver in many countries there are insufficient num-bers of health workers to meet urgent needs, even to deal effectively with the traditional problems of communicable diseases. Where health workers are in place, they are often inadequately organ-ized and managed, and deployed inequitably. If unaddressed, the increasing burden of NCDs will exacerbate the health crisis in many countries. The Alliance has been working through its members and partners to influence the new WHO NCD Action Plan for 2013-2020, and ensure adequate training, management, and support to health workers in treating NCDs, within strengthened and effective health systems.

The post-2015 development agenda

During its first five years, the Alliance has had a major impact in improving access to and the perfor-mance of health workers. The critical contributions

The Alliance strives for greater access to and the improved performance of the health workforce. It puts health workers at the heart of its activities by advocating for increased donor support and country investment, better targeting of resources, strengthened institutions and health systems, and empowered workers, to save lives and achieve the MDGs. This role has been recognized by minis-tries of health as “...keeping HRH issues high on the international agenda…” leading to “…greater engagement by partners in supporting HRH and health systems strengthening. Previously these were a non-issue.”(from the independent external assessment of the Alliance).

Shifts in global disease burden

As the global burden of disease shifts from infec-tious diseases and maternal and child health (MCH) conditions to noncommunicable diseases (NCDs), new demands are being made on health workers to cope with emerging needs. Health workers in

towards strengthening health systems and UHC continued in 2012, with the launch of its new strat-egy for 2013-2016, Advancing the health workforce agenda within universal health coverage. The strategy focuses on improving Alliance opera-tions to achieve greater results, strengthening monitoring and accountability of the HRH agenda, and ensuring the agenda is integrated into the UHC policy discourse and post-2015 development agenda.

The international community and countries must initiate HRH-related actions that contribute to UHC, including: increasing volumes and improving the quality of investments; implementing effec-tive policy options; strengthening institutions to train health workers, and ministries of health to manage them; improving mechanisms to facilitate policy dialogue, and develop national HRH strate-gies and plans; and generating evidence on HRH availability. Moreover, the Alliance advocates for HRH-specific benchmarks in the UHC framework

and post-2015 development agenda. This would contribute to improving collaboration between countries and global partners, and to focus policy actions and investment decisions where they are needed.

Integrating human resources for health into key policy processes

A key area of the Alliance’s success is the incorpo-ration of an HRH perspective on health workforce targets in major policy and development processes (for example, the UN Global Strategy for Women’s and Children’s Health, the NCD, Human immunode-ficiency virus [HIV], and other United Nations High Level Meetings, and G8 summits), resulting in its inclusion in policy documents, declarations, and commitments. In 2012, the Alliance represented the HRH agenda at major events and meetings:

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1. Advocating for health workers to be at the heart of the global health agenda

2. Facilitating country actions

3. Promoting evidence-based HRH solutions

4. Management and Governing bodies

5. Looking forward

2012UnitedNationsConferenceonSustainableDevelopment(‘Rio+20’)The Alliance, working through its members and civil society partners, influenced the messaging for the ‘United Nations Conference on Sustain-able Development’ (‘Rio+20’), held in Rio de Janeiro, Brazil during June 2012. The final ‘Rio+20’ Declaration called for “further collaboration and cooperation at national and international levels to strengthen health systems through increased health financing, recruitment, development, training and retention of the health workforce, improved distribution and access to safe, affordable, effective and quality medicines, vaccines and medical technologies, and through improving health infrastructure.”

2012FamilyPlanningSummitThe Alliance collaborated with WHO to develop policy briefs On optimizing the health workforce for effective family planning services for the ‘2012 Family Planning Summit’ in London in July 2012. The briefs represent strategies to improve family planning care and strengthen sexual and reproductive health services in developing countries. WHO called for a strengthened workforce to deliver services to women and girls in the poorest countries. The Summit was organized by the UK Government’s Department for International Development (DFID), the Bill and Melinda Gates Foundation, the United Nations Population Fund (UNFPA) and other partners.

BerlinWorldHealthSummit2012The Alliance Secretariat – with Monash University (Australia) and WHO – organized a session entitled ‘Transformative Health Professionals Educa-tion for the 21st century’ at the ‘World Health Summit’ in Berlin, Germany during October 2012. The theme of the summit was ‘Research for Health and Sustainable Development’ as a way of improving healthcare systems and finding new solutions for NCDs and other global health concerns. The Alliance event engaged and informed participants about health education initiatives to build momentum for enhancing health workforce education, as part of health system strengthening.

GlobalhealthinitiativesengagedforimprovedopportunitiesforHRHfundingThe Alliance took part in consultations with the Global Fund to Fight AIDS, Tuberculosis and Malaria (‘Global Fund’) Board member, advocating for a greater focus on health workforce development in the Global Fund funding approach. The new funding model adopted by the Global Fund represents progress in better aligning the support provided to national mechanisms with their needs, including those related to the health workforce.

ParliamentaryhearingonimplementationoftheWHOCodeofPracticeonInternationalRecruitmentofHealthPersonnel2012The Alliance participated in the hearing in Germany in January 2012 at the Bundestag Parliamentary Sub-Committee on Health in Developing Countries-Code of Practice. The Alliance issued a statement on the Global Code of Practice for the International Recruitment of Health Personnel/ migration. Priority actions for developed countries were highlighted, including domestic policies of member states, ensuring ethical principles in the international recruitment of health personnel, avoiding recruitment from countries facing critical shortages and striving for self-sufficiency in terms of the production of sufficient numbers of health personnel.

IrishForumforGlobalHealthInternational2012The Forum recognized the critical shortage of skilled health personnel as one of the greatest challenges facing global health today. Irish and inter-national practitioners, NGOs, researchers, government agencies and the private sector renewed efforts towards putting knowledge on the health workforce into policy and practice for achievement of the MDGs and future global health goals. Participants agreed on priority issues to be addressed to achieve a sustainable and effective health workforce in all countries, including education and training, institutional partnerships for capacity building, health worker motivation and retention, and community-based responses. ThirdGlobalForumonHumanResourcesforHealthThe ‘Third Global Forum on Human Resources for Health’ in 2013, will be crucial in mainstreaming HRH in consultations on the post-2015 develop-ment framework. Key decisions on the strategic focus, leadership, and structure of the Forum were made at the 14th Alliance Board meeting in Tunis in July 2012. It was agreed that the Forum would be held in Recife, Brazil in November 2013, under the patronage of the Government of Brazil, WHO and the Pan-American Health Organization (PAHO). The Forum is the main mechanism through which the Alliance convenes its members and partners. The theme of the forum will be ‘Human resources for health: foundation for universal health coverage and the post-2015 development agenda’, with the objectives of placing HRH in UHC and the post-2015/MDG devel-opment framework; and obtaining new tangible HRH commitments from countries, agencies, and partners to further advance the HRH agenda. The Alliance has established and convened the governance structures: the Forum Organizing Committee and the Forum Working Group, to advice and assist in preparations.

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5. Looking forward

together HRH stakeholders and create opportunities for policy discus-sion and visibility for HRH. The number of participants has risen from 50 in the early years to 250 in 2012. The 7th Annual Conference in Thailand, in November 2012, agreed that to enable more time and resources for organizing activities at country level, the conference would take place every two years, instead of annually. The AAAH focal points in member countries reported on the HRH situation in their countries, contributing to regional monitoring of the situation (including the number of health work-ers, and plans for UHC and HRH). The Alliance partnered with CapacityPlus to organize a session on health worker productivity, which in addition to the dynamic discussion, provided input for the CapacityPlus draft tool on improving HRH productivity.

AfricanPlatformforHumanResourcesforHealth(APHRH)The Alliance Secretariat took part in and supported the governance reorganization of the African Platform for Human Resources for Health (APHRH), leading to a new Secretariat and Steering Committee, and

Regional networks for HRH policy dialogue strengthened

The Alliance successfully collaborates with and strengthens regional networks. This collaboration is critical for advocacy efforts to advance the HRH agenda in regions, and countries. In 2012, the Alliance collaborated on significant initiatives to provide a platform for policy dialogue and exchange of learning and best practices:

Asian-PacificActionAllianceforHumanResourcesforHealth(AAAH)The Alliance supports the Asian-Pacific Action Alliance for Human Resources for Health (AAAH) in organizing annual conferences that bring

SensitizingpoliticalleadershiponHRHthroughadvocacyevents Box2

The Alliance catalyzes national leaderships to improve HRH coordination and management – including between

government, the private sector, and civil society – and adopt policies to strengthen the health workforce. In

2012, the Secretariat participated in, facilitated, provided substantive inputs into, or funded key advocacy

events focused on HRH: 1. HRH event organized by Bangladeshi civil society organization Development Organization for the Rural

Poor (DORP), with Alliance and Health Workforce Advocacy Initiative (HWAI) support: on stakeholder

dialogue on HRH, resulting in greater collaboration. Subsequently, the organizers developed a position

paper on the Community Health Care Provider (CHCP) programme in Bangladesh, which was submitted

and approved for the Asian-Pacific Action Alliance for Human Resources for Health (AAAH) conference,

Bangladesh (March). 2. Meeting of the All-Party Parliamentary Group on Global Health and Africa in the UK (March). 3. Meeting of the Swiss Interdepartmental Group on Migration and Health Workforce on ‘International

migration of health personnel to Switzerland’ in Switzerland (April).4. Meeting on ‘Engaging with the private sector in health in Africa’, in collaboration with the Government of

Germany and USAID in Tanzania (May).5. ‘5th annual conference of the International Academy of Physician Associate Educators (IAPAE)’: the Alli-

ance Secretariat presented draft findings of a review and country case studies in a session on mid-level

providers, in South Africa (September).6. Briefing on the ‘Global Code of Practice for the International Recruitment of Health Personnel’ (‘the

Code’) for the Parliamentary Group on Health and International Development Cooperation of the Austrian

Parliament, in Austria (October).7. Hosted ‘Stand Up for Health Workers’ event, in partnership with the Permanent Mission of Ireland to the

UN: to inform the health community on ‘the Code’ and review progress in its implementation, in Switzer-

land (October). 8. The Economist conference on ‘The Global Healthcare summit - Building a unified vision’, supported by

the Alliance as an associate partner, where an HRH-focused intervention prepared by the Secretariat was

delivered by a Board member, in the UK (November).

TheHealthWorkforceAdvocacyInitiative Box3

Members of the Health Workforce Advocacy Initiative (HWAI) – supported and funded by the Alliance Secre-

tariat – make a major contribution to human resources for health (HRH) advocacy. HWAI conducted research,

policy analysis and advocacy to inform and influence the Global Fund to Fight AIDS, TB and Malaria, Interna-

tional Health Partnership, G8 processes, and other global, regional and country initiatives: > In 2012, HWAI members in Uganda successfully lobbied the Government of Uganda to increase the budget

for, and number of health care workers. Over 6,000 new health workers will be recruited at health centres

throughout Uganda, including medical doctors, nurses and midwives;> HWAI supported an HRH event organized by Bangladeshi civil society organization Development Organi-

zation for the Rural Poor (DORP) to facilitate stakeholder dialogue on HRH.

In February 2012, a civil society consultation was held to develop an HRH advocacy strategy for HWAI itself.

HWAI members agreed to focus on advocating for the adoption and implementation at national and interna-

tional levels of new benchmarks and targets, evidence and guidance on HRH development (including ‘the

Code’), rural retention, scaling-up of health professional education and training, and increasing the role of

community health workers (CHWs) and mid-level health providers (MLHPs). The HWAI Secretariat will also

advocate for increased resources for HRH at national and international levels in order to improve distribution of

and access to health workers. HWAI members provided substantive inputs into the development of the Alliance

strategy for 2013-2106.

In 2012, the HWAI Secretariat moved from Wemos (Netherlands) to a partnership between AMREF (Kenya) and

Intrahealth International (United States).

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5. Looking forward

strategy and operational plan being put in place. The Alliance also pro-vided financial support to a regional HRH partner mapping exercise, to enlarge and strengthen the network. The APHRH co-organized a synthesis meeting on community health workers (CHWs), resulting in the develop-ment of a global mechanism for coordinated support by partners, a needs-based priority research agenda, and a global monitoring framework and set of best practices.

HarmonizationforHealthinAfrica(HHA)The Alliance – an associate member of Harmonization for Health in Africa (HHA) – influenced the agenda of the HHA conference for African Ministers of Finance, and Health, through its strategic input and a technical brief, to include a session on HRH and financing, provided input for discussions, and participated in the ‘HRH Financing’ and ‘Equity Agenda’ sessions. Ministers adopted the Tunis Declaration, the framework to be used by governments and other stakeholders to engage in concrete programmes for improving capacity to plan and budget for results and achieving the health-related MDGs. The outcome statement of the conference under-lined the importance to “Improve efficiency in health systems, including equitable access to skilled health workers”, which was also reflected in the action plan to implement conference recommendations.

AfricanPublicHealthAlliance(APHA):15percentcampaignThe Alliance Secretariat engaged with and provided financial support to the African Public Health Alliance (APHA), as a member of HWAI, to advo-cate for inclusion of HRH issues in the African political process (including with the African Union [AU]). Through advocacy and lobbying, HRH was highlighted as a must-tackle issue in the Africa Integrated RMNCH Strat-egy developed by the Africa Maternal, Newborn and Child Health (MNCH) Coalition and partners, led by the AU Commission, in August 2011 in Zam-bia. This success will ensure that HRH is high on the agenda for MNCH. Other key APHA events included:> The ‘ConferenceofMinistersofEducationoftheAfricanUnion’

took place in April 2012 in Nigeria. The APHA, in partnership with the Alliance Secretariat, influenced the conference to include a recom-mendation for a ‘Call on Regional Economic Commissions (RECs) and Member States to enhance multisectoral collaboration in view of the fact that education is key to development and provision of human resources in every sector’, which was also submitted at the AU Summit in July 2012. The recommendation provides an entry point to engage with the AU Commission and RECs/Member States on the need to facilitate the development of an African Human Development Resources Plan (including HRH).

> The Pan-AfricanParliament adopted key resolutions in October 2012: • To engage with health, and non-health sectors for a multisectoral

approach to improving the health of women and children, through improved policy, and investment in the health sector; and tackling non-health sector challenges such as improved education for HRH;

• To commit to promoting policy cohesion and monitoring for account-ability on the implementation of global, regional and country poli-cies and commitments made to improving maternal and child health, especially those related to improving training, recruitment and retention of HRH.

Corporate communications

The Alliance ensured a wider use of knowledge products in 2012 and increased its visibility and brand recognition through the development and dissemination of monthly newsletters, frequent web stories, regular Facebook updates, and tweets and other social media output. An annual report for 2011 was developed and published.

Website content continued to grow and diversify, with new materials available in French and Spanish. Country web profiles have been added. Website usage increased to 52,261 visits in December 2012 (see Figure 1 below), and in every month in 2012 there was a minimum of 40,000 visitors (this analysis only counts ‘unique visitors’, i.e. users visiting the site for a second time in the same period are not counted).

Linkages and cross-references between the Alliance website and the CapacityPlus Global Resource Center on HRH have been strengthened. A new marketing and dissemination strategy was approved – for market-ing and outreach activities in 2013 – to accompany the new strategy for 2013-20161.

1 See http://www.who.int/workforcealliance/knowledge/resources/annualreport2011/en/ for further details.

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5. Looking forward

Figure1:Websiteuniqueusersandmonthlyvisitsfrom2009-2012 Improvinghealthservicesatthecommunitylevel Box4

Despite chronic shortages of health workers, there are other ways for countries to maximize health worker

productivity. One is through optimizing the skills mix. Task sharing can potentially increase the productivity

and efficiency of health care delivery, and the number of services provided, while preserving quality.

There is also evidence that community health workers (CHWs) and frontline health workers can provide

inexpensive, safe and effective health services at the community level, for example, information to pregnant

mothers, diagnosis, treatment or referral for pneumonia or TB, organization of vaccination days, ORS for diar-

rhoea and micronutrient supplements for malnutrition. They are often the only provider of health care in rural

or remote areas, and play a key role in linking families and communities to the health system. Without CHWs,

there would be no health care for millions of people. With more CHWs – together with better training, skills,

equipment and information – many more lives could be saved.

The Alliance urges countries and donors to increase investment, and integrate community-based health work-

ers into national health systems. In 2012, the Alliance supported and facilitated policy dialogue and advocacy

initiatives:> A consultation on the role of community-based providers in improving maternal, newborn and child health

(MNCH) in May 2012 (organized by the Royal Tropical Institute, Netherlands);> An evidence summit on ‘Community and Formal System Support for Enhanced Community Health Worker

Performance’ in May 2012 (convened by the USAID Global Health Bureau); > A ‘Community Health Worker Regional Meeting’ in Ethiopia in June 2012 (convened by the USAID funded

Health Care Improvement Project);> A consultation on ‘Health workers at the Frontline – Acting on what we know: Consultation on how to

improve frontline access to evidence-based interventions by skilled health care providers’ in Kenya in June

2012 (convened by the Norwegian Agency for Development Cooperation [NORAD] and coordinated by the

European Network of Specialized National Equality Bodies [EQUINET]). > Development of a ‘Joint Statement’ to harmonize and create linkages among various initiatives.

The Alliance reviewed data on national policies on CHWs revealing that the number of countries allowing them

to manage pneumonia more than doubled, from 18 in 2008 to 38 in 2012*. Support from, and integration within

the health system, are critical factors in determining the effectiveness of CHW programmes.

0

10 000

20 000

30 000

40 000

50 000

60 000

Dec-12

Aug-12

Jul-1

2

Apr-12

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-11

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Sep-10

Jul-1

0

Mar-10

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Monthly visits Jan 2009 – Nov 2012

11 4

70

20 4

61

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30 9

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46

20 6

02

29 4

34

27 0

52

43 0

73

44 7

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1547

303 52

261

22 23





5. Looking forward

Figure 2: Countries authorizing community health workers to diagnose and treat pneumonia

0

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Mariam Louise Walusimbi, Critical Care Nurse in Uganda: “I really had a passion to take care of the sick. So that’s how I really wanted to become a health worker. My basic nursing is critical care and that is what I enjoy the most. Because these are the patients who have failed from any other units and have the criteria to be taken care of in a critical care unit. And these are patients who everybody thinks now they cannot be salvaged. But then you salvage this patient and you see this patient waking up and this patient walks out of the hospital healthy. That motivates me a lot.”

Fatiya Askederin, Strategic Information Officer in Nigeria:“I’m the Strategic Information Officer for Heartland Alliance, and I’m a health worker. What I like most about it is just coming home and knowing that I’ve had a good day and I’ve helped somebody, because for every day you work, you have had an impact on somebody’s life. The biggest challenge I face has to do with infrastructure of facilities and the policy environment where we work. I think what would help us all is just having the right infrastructure in place so that people can access services, there are drugs provided, and the healthcare workers have good training to be able to support people and provide care.”


Mariam Louise Walusimbi


Fatiya Askederin

Facilitating country actions

identified by WHO in 2006 to have a critical short-age of health workers (see Figure 3 below): > 19haveincreased their aggregate HRH

density. There has been substantive progress in Indonesia (from 0.95 per 1,000 to 2.33 per 1,000), Peru (from 1.84 to 2.19) and Uganda (from 0.79 to 1.43), and major progress also in Burkina Faso, Djibouti, Ethiopia, Ghana, Iraq, Morocco and Pakistan.

> Significant improvements in health worker availability have been achieved by scaling-up the training of MLHWs and CHWs. Ethiopia has trained and deployed 30,000 community health extension workers in the public health system, and Pakistan trained over 100,000 female health workers. These workers are not captured in formal statistics that focus on higher level personnel, but play a fundamental role in improving access to essential health services.

The Alliance supports countries to finance, train, deploy, and retain an effective health workforce, and improve the quality of health services. Health worker shortages exist due to underinvestment in health education, increases in disease burden, internal migration of existing workers from rural to urban areas, external migration from develop-ing countries to developed ones, low salaries, and poor working conditions. The Alliance works to improve the policy environment for HRH devel-opment, utilizing global policy processes and advocacy. In 2012, the Secretariat supported 12 existing countries to strengthen their health work-force and develop and implement HRH plans, and extended assistance to five additional countries.

The Alliance has helped countries to make signifi-cant progress in addressing HRH shortages (based on data available in 2012 that reflect updates from countries up to 2009). Among the 57 countries

> 20donothavenewdatapoints (after 2006), making it difficult to ascertain progress in tackling health workforce shortages. The Alliance advocates for and supports the expansion of national and regional mecha-nisms to collect, analyze and disseminate relevant health workforce information, such as the network of national and regional HRH observatories.

> 18haveseenareduction in HRH density. However, this finding should be viewed with caution: among countries for which the WHO database indicates reductions in density, many cases are thought to result from variability and accuracy in data sources. In Malawi, for example – which showed a decrease in density – a marked improvement in HRH density has

been documented through an independent external evaluation of the national Emergency Human Resources Programme,2 suggesting an imperfect information basis in the WHO Global Atlas (in other countries, including the Congo, Gambia and Sierra Leone, the reduction in the combined density of physicians, nurses and midwives is real, possibly as a result of out-migration).

The Alliance’s 2013-2016 strategy recognizes that the HRH crisis is a global one, and not limited to the 57 countries. The Alliance’s work will in future be directed at health systems in all countries, including middle- and high-income ones (where, for example, under-funding of training also exists, and where there can be an over-reliance on migrant

2 See www.who.int/entity/workforcealliance/media/news/2010/Malawi_MSH_MSC_EHRP_Final.pdf for further details.

26 27





5. Looking forward

HowtheAlliancepromotescountryactionsthroughitsmembersandpartners Box5

1. DevelopingandimplementingHRHstrategies,policiesandplans:> Strengthens leadership capacity to develop, implement, and monitor HRH strategies, policies and

plans.> Generates data, evidence and intelligence to improve policy development, implementation and

evaluation.2. Increasinghealthworkernumbers:

> Supports efforts and advocates for increases in HRH investments.> Develops and implements evidence-based, health workforce strategies and plans, within a policy

framework that includes appropriate legislation, regulation, and funding.

3. Increasingtrainingandeducation:> Develops training plans to ensure the needed numbers and types of health workers, and to upgrade

the skills of current health workers.> Strengthens health worker education through improved resources and facilities; and continuing

professional development and in-service training.

4. Deployinghealthworkerswhereneeded:> Supports and advocates to countries to improve distribution of health workers and increase access of

rural and remote populations to health workers.

5. Strengtheninghealthworkforcemanagement:> Advocates to and helps countries to improve health workforce management to support health work-

ers, and ensure better working conditions, incentives, and sufficient equipment and supplies.> Provides countries with practical tools and approaches to increase health worker motivation, recruit-

ment, retention, and productivity.

6. Strengtheningpartnerships:> Promotes and strengthens networking and partnerships at national and regional level.

health workers). However, a specific focus will be given to the 75 countries that account for 97 percent of maternal and child deaths globally.

Improving the policy environment for HRH development

The Alliance Secretariat has initiated an effective approach and set of principles to support countries in developing their health workforces, and improving the health of their populations. The approach is based upon

country coordination and facilitation (CCF) to identify national health workforce gaps, and translate them into targets for health workforce plans in national health strategies. The CCF approach builds on existing country processes and mechanisms, bringing together all stakeholders to strengthen collaboration, and develop, implement, coordinate and moni-tor HRH plans (seeFigure4). The CCF approach has already seen positive results in countries, for example, increased resources – both domestic and international – to HRH, greater political commitment to HRH (including integration of HRH in national health system strategies), scaled-up training of health workers, and improved health worker capacities.

The approach will be scaled-up during 2013-2016 to strengthen health systems through increased support to improve training, distribution and performance of health workers, better HRH planning and coordination, mobilization of more members to become responsible for providing CCF assistance, and greater emphasis on analyzing, documenting, and sharing best practices in national HRH processes.

Figure3:Progressintacklinghumanresourcesforhealthshortagesinprioritycountries

“I would like to thank them [the Alliance] for the support given to my country through their excellent initiative, the country coordination and facilitation approach to tackle the human resources for health crisis.”Dr Maria Isabel Rodriguez, Minister of Health of El Salvador.

decreasing HRH density

improving HRH density

no new datasince 2004-2005

2018

19

28 29





5. Looking forward

Figure4:Sixstepsinthecountrycoordinationandfacilitationapproach

3 See http://www.who.int/workforcealliance/about/governance/board/ghwaee_annexes/en/index.html for further details.

Embedded and integrated in national health policy dialogue and national health strategy.

Major steps on HRH in the CCF process

Step 2HRHSituationanalysis

Step 1HRHcoordinationmechanism

Step 3HRH plandevelopment

Step 4Resourcemobilization

Step 5HRH planimplemen-tation

Step 6M&Eof HRH plan

Since 2009, the Alliance Secretariat has provided technical and financial support to 24 countries in improving their health workforce development policy processes, and implementing strategies and plans (see Figure 5). Independent assessments confirm that the Alliance’s support is highly effective3 and regarded as crucial in some countries.

Figure5:ResultsofAlliancesupportto24countries(2009-2012)

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CCF Progress 2009-2012

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Rosa Lara de Forela, Sub-Director of nursing in Guatemala:“I have a degree in nursing. I like providing support and care to patients. The most satisfying thing I’ve found in my profession is giving direct attention to each of the patients that I encounter in different departments of the hospital. I like to serve mankind. That’s my passion. Currently the hospital has an exces-sively high patient demand. We have a capacity of 208 beds, but we serve 240 to 260 patients. What we need, what I would like to receive, is to expand the infrastructure and have more human resources, because in nursing there are few human resources.”


Rosa Lara de Forel

30 31





5. Looking forward

Country progress in developing and implementing health workforce strategies through CCF

Countries are ultimately responsible for progress in improving their health workforce. During 2012, numerous countries – with Alliance support – have taken significant steps to improve coordination and leadership, develop health workforce capacity, scale-up education and training, and incentiv-ize and retain an effective, motivated workforce:

Pakistan• Enrolment of doctors increased in Pakistan from 139,555 in 2009 to 150,667

in 2011; nurses from 9,822 to 11,269 over the same period; and midwives from 50,968 in 2009 to 53,625 in 2010.

Indonesia• An Alliance case study quantified Indonesia’s increased Ministry of Health

investment in HRH development: budget allocation rose from 2,319.76 billion Indonesian Rupiah (IDR) in 2010 to 2,928.41 billion IDR in 2012, with a further rise planned to 3,739.42 billion IDR in 2014.

• Access to health workers in remote areas increased through the recruitment of nurses, health promotion personnel, nutritionists, and laboratory assis-tants (e.g. the number of health workers increased from 303 in 2010, to 1,275 in 2011).

Sudan• Sudan strengthened its HRH management capacity through an increase of

States with dedicated HRH directorates (from less than 10 percent to 55 percent).

• 15 Continuous Professional Development centres have been established in 15 states and 25 at hospitals since 2009. There were 674 training courses in different disciplines, and 32,902 health staff trained during this period.

• The ratio of doctors to nurses improved from 1:1.7 to 1:2.5.

SouthSudan• Enrolment of HRH trainees increased in South Sudan from 260 to 377, includ-

ing nurses from 60 in 2011 to 91 in 2012, and community midwives from 90 to 181 over the same period.

Cameroon• Alliance advocacy and support led to Cameroon increasing investment in

HRH and reopening its midwifery school after 15 years – in response to new evidence of increased maternal mortality.

Chad• Chad adopted CCF principles in its HRH coordination mechanisms, and accel-

erated the recruitment of doctors, nurses, and midwives for deployment in remote areas: in 2012, an additional 1,000 health workers (850 professional and 150 administrators) were recruited, and the development of a pre-service training programme for midwives is ongoing.

Zambia• Zambia improved the accessibility of health services – following CCF princi-

ples – through increased use of CHWs at the primary services level. • The focus on HRH coordination and planning at national level resulted in:

– a significant drop in the vacancy rate of public sector nurses (from 30 per-cent in 2008-2009 to 10 percent in 2011), and a corresponding increase in institutional deliveries from around 50 percent to over 75 percent.

– CHW strategy developed to train community health assistants with six months theory and six months practical clinical training, using 11 specially designed modules. The first intake was in June 2011 and in 2012 the pro-gramme was extended to 7 provinces and 48 districts, with over 300 CHWs undergoing training.

– the number of clinical staff increasing from 12,173 in 2005 to 17,682 at the end of May 2011 (including an additional 1,573 nurses, 400 environmental health staff, 398 midwives, 374 clinical officers, 265 doctors, 263 pharma-cists, and 74 nutritionists).

– Outward migration of nurses – which peaked at 590 in 2003-2004 – has declined to less than 30 per year for the past three years.

Zimbabwe• A harmonized retention policy resulted in a significant drop in the public sec-

tor nurse vacancy rate in Zimbabwe, from 30 percent in 2008 and 2009, to 13 percent in 2011.

Master’s programme in HRH management for francophone countries

The Alliance works with partners to ensure that a new generation of young people are provided with the highest possible level of health education. In 2012, the first 37 distance learning students completed the Masters Pro-gramme in Public Health, with a focus on HRH leadership and management. The programme was taught in French to students from 10 French-speaking countries (Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Mali and Senegal). The programme – implemented in collaboration with the Uni-versity of Geneva (Switzerland) and WHO – addresses gaps in capacity for health workforce strategy formulation, planning and management, which are key constraints in HRH development in developing countries.

32 33





5. Looking forward

Assessments and country profiles

The Alliance assists countries in improving their health services by gen-erating knowledge and information, such as case studies, and country profiles. CountrycasestudiesThe Alliance Secretariat developed case studies for Cameroon, Indonesia, Nigeria, Sudan, Zambia and Zimbabwe to document the HRH coordination, planning and development processes, and to assess the effectiveness

of Alliance support. The studies highlight the HRH challenges, and the policy and planning actions taken to address them in each country. Alliance support to promote CCF principles was examined, and found to be relevant, effective, and appreciated by national stakeholders. Rec-ommendations are provided to both national and international stakeholders to improve effec-tiveness of support to HRH development in the future4.

WebsitecountryprofilesThe Alliance supported the development of web profiles for 22 HRH priority countries. The pro-files provide concise and accessible information, with links to additional comprehensive sources of country-specific information on health work-

force challenges and the Alliance’s response. In addition to health work-force data and statistics, the profiles provide analysis of health workforce trends, links to the latest plans, policies, and case studies, and a list of Alliance members working in the country5.

4 See http://www.who.int/workforcealliance/knowledge/en for further details.5 See http://www.who.int/workforcealliance/countries/countryprofiles/en/index.html for

further details.

HRHdevelopmentinAfricatoimprovematernalandchildhealth(MuskokaProject) Box6

The Alliance supported the application of country coordination and facilitation (CCF) principles in the context

of a programme funded by the Government of France. The programme is part of the government’s commitment

to the Muskoka Initiative (from the G8 meeting in Muskoka, Canada, in June 2010), allocating 500 million Euros

during 2011-2015 to accelerate the achievement of MDG4 (reducing child mortality) and MDG5 (improving

maternal health) in 14 Francophone African countries, and Haiti.

The grant was awarded to WHO and the Alliance Secretariat, in partnership with other UN agencies including

the United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF) and UN Women. The

WHO/Alliance component is for: family planning; strengthening the quality of essential obstetric care and

neonatal emergency care; integrated childhood diseases at community level; strengthening human resources

for health (HRH), led by the Alliance; and pharmaceutical systems to improve health care services.

Alliance technical and financial support in 2012, focused on: developing the baseline and revision of HRH plans

for reproductive health and maternal, newborn and child health (MNCH) services; planning of harmonized

action among UN agencies; and midwifery practices assessments in DR Congo, Guinea and Togo to revise HRH

plans in line with the objectives of health plans related to MDGs 4 and 5.

Desk reviews in some countries identified shortages of midwives and nurses in remote areas, poor deployment

of health workers, inadequate retention strategies due to the removal of user fees for maternal and newborn

services, and a lack of coherence between MNCH training programmes and services needed. UN agencies,

bilateral partners and national stakeholders will be mobilized to resolve these issues by: > Strengthening paramedical training schools by implementing e-learning and m-learning programmes to

scale-up the education of MNCH workers.> Ensuring an accreditation process for training schools, and developing and implementing a regulation

process for improving quality.> Revising retention strategies in line with the free MNCH services strategies.> Developing MNCH worker deployment strategies (and advocacy).

Beneficiary countries are: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Côte d’Ivoire,

Democratic Republic of Congo, Guinea, Madagascar, Mali, Mauritania, Niger, Senegal, Togo and Haiti. Four

countries – Côte d’Ivoire, Guinea, Mali and Togo – have been selected as recipients of joint UN Agency support.

“Since the implementation of the country coordination and facilitation process in Cameroon, human resources for health issues are better understood, because there is a consensus among various stakeholders. We hope that the implementation of the new strategic plan for the second phase will enable Francophone countries to expedite tackling the human resources for health challenges.”The Honourable André MAMA FOUDA, Health Minister of Cameroon.

Promoting evidence-based HRH solutions

sub-Saharan Africa. The analysis – undertaken by leading Australian and UK academics, with finan-cial support from WB – examines methodological approaches and existing evidence on the interplay between social, economic, health system and human motivational factors in affecting the supply and demand of health workers in low- and middle-income countries, with a particular focus on Africa. The findings will be disseminated at a dedicated consultation in Tunis in 2013 (co-funded by WB, ADB and the Alliance Secretariat).

Assisting countries to develop human re-sources for health plans and assess impact

Effective country actions must be evidence-based, thus the Alliance works with members and part-ners to develop resources and tools to support countries in improving their health workforces.The Alliance developed an HRH toolkit to bring together existing tools in use for country-level HRH development (including those for situation

Evidence and strategic intelligence are essential for high-level advocacy and accountability. The Alliance continuously monitors, scrutinises, and reports on HRH actions and impact to address gaps, and to ensure greater accountability of HRH stakeholders on their commitments. Specific benchmarks and indicators are vital – as with the MDGs – to enable progress on HRH availability and development to be tracked. These measures dem-onstrate the impact of HRH investment through lives saved, improved population health, and socio-economic development.

Policy dialogue on HRH labour markets in Africa facilitated

The Alliance Secretariat – in collaboration with the World Bank (WB), African Development Bank (ADB) and Alliance member, CapacityPlus – con-tributed towards the development of a method-ology, and conducted a systematic review, on labour market forces affecting HRH dynamics in

analysis, planning, implementation, and monitor-ing and evaluation). The toolkit (including products of the Alliance and others used in addressing HRH issues) is based on the structure of the Human Resources for Health Action Framework (HAF), and will help countries to develop, implement, and monitor evidence-based HRH plans6.

The Alliance also supported the development of an HRH policy impact assessment tool (PIAT) to assist in documentation and accountability efforts, by enabling countries to systematize the collection and analysis of relevant data. The tool will help to inform decisions in view of limited financial resources, and to demonstrate accountability for the resources invested. The tool has been used in a pilot phase in Bangladesh and Tanzania, con-tributing to health workforce policy dialogue and planning7.

6 See http://www.who.int/workforcealliance/media/news/2012/toolkitlaunch/en/ for further details.7 See http://www.who.int/workforcealliance/knowledge/toolkit/5/en/ for further details.

36 37





5. Looking forward

The role of the private sector in HRH development

The role of the private sector in contributing to the development of health services is currently underexploited in many developing countries. The Alliance is committed to greater engagement with the private sector. The Secretariat completed the Private Sector Task Force Report and launched it during the 65th World Health Assembly in 2012. The Private Sector Task Force (PSTF) reviewed 31 initia-tives in low-income countries (primarily in Africa) that increased the supply, improved the effective-ness, and/or reduced attrition or poor distribution of health workers. The PSTF also contributed to the scaling-up and cross-border implementation of three private health sector initiatives in Kenya, Mali, and Zambia. Based on these experiences, the PSTF identified key factors that can determine the

Howeffectivearemid-levelhealthworkers?TheresultsoftheAlliance’sanalysis. Box7

The Alliance Secretariat commissioned analysis (based on a global systematic review and eight country case

studies in low- and middle-income countries) to investigate the global experience of mid-level health workers

(MLHWs), their effectiveness and impact on the health-related MDGs and other priority health services, and

how they can be integrated into national health systems. Findings include: > MLHWs play an important role in the delivery of maternal and child health services (including minor

surgery), anti-retroviral therapy, health promotion, and prevention and care for NCDs.> No statistically significant differences were found in quality of care delivered by MLHWs compared with

physicians: in a few outcome measures MLHW outperformed physicians. > MLHWs can contribute to a more efficient human resources skills mix, which can mitigate the effect of

health workforce shortages and better enable countries to meet or make progress towards attaining the

MDGs.> MLHWs should be included as part of the general planning and management of the health system, and

equally benefit from support, supervision, regulation, quality control, and opportunities for professional

development and career progression.

The findings were compiled into a Technical Briefing and presented at the IAPAE conference in South Africa, in

September 2012; and informed proceedings at a session organized by the Alliance Secretariat at the ‘Second

Global Symposium on Health System Research’, in Beijing in November 2012.

8 See http://www.who.int/workforcealliance/media/news/2012/pstfreportlaunch/en for further details.9 See http://www.sciedu.ca/journal/index.php/jha/article/view/1843 for further details.

success or failure of private sector HRH initiatives, and proposed actions to facilitate private sector involvement in enhancing the quality and man-agement of health services and health workforce development initiatives8.

Monitoring human resources for health interventions

The Alliance monitors country actions as a key aspect of accountability by stakeholders. A progress report on the implementation of KD-AGA was developed in January 2011, as part of the preparation for the Second Global Forum. The report reviewed the policy environment for HRH development in 57 HRH priority countries with severe health workforce challenges, and set a baseline for future evidence-based monitoring of progress and accountability. In 2012, the Alliance Secretariat (and external consultants) analyzed the report findings and found a significant correlation between having and implementing an HRH plan and other variables (e.g. the likeli-hood of introducing strategies for retention of health workers in under-served areas were four times higher in countries implementing a national plan than those not).

The analysis demonstrated that progress in addressing HRH challenges appears to be independent of contextual factors, suggesting that coun-tries can improve their performance through concerted action by stake-holders. Having and implementing an HRH plan appears to be a key factor in galvanising action. The significance of the analysis lies also in the fact that it helped identify the relative importance and significance of the indi-cators tracked, as only some of them appear to correlate significantly with the broader dimension of HRH performance. This finding will inform the design and the methodology of the next progress report.

The Alliance is developing a new report, the Human Resources for Health Progress Report on implementation of the Kampala Declaration (and other processes), which will be launched at the ‘Third Global Forum on HRH’ in Brazil, in 2013. The new report builds on the analysis conducted for the Second Global Forum9, and expands it to provide an objective assessment of progress in improving HRH, and as a basis and framework for account-ability. A preliminary analysis has been conducted to update the list of indicators tracked and strengthen the methodology, to address some limitations that were apparent in the first progress report.

Management and Governing bodies

The Alliance Board used the external evaluation as an opportunity for realigning its strategic pri-orities to ensure that it continues to play a unique catalytic role in the future. The Board held its 13th meeting in February 2012, focused on a review of the findings of the external evaluation; and its 14th meeting in July 2012, which laid the founda-tions for the development of the new strategy for 2013-2016.

The new Alliance strategy for 2013-2016

Building on the findings of the external evaluation, and through an inclusive consultative process, the Alliance developed a new strategic framework for 2013-2016: Advancing the health workforce agenda within universal health coverage. The process also included a public consultation, a pre- launch at the 65th World Health Assembly, and a formal launch at an inter-ministerial conference in

External evaluation

The external evaluation conducted in late-2011/early 2012) concluded that the Alliance had made a critical contribution in moving forward the health workforce agenda at global and country levels, provided effective support to countries through the CCF approach, and represented good value for money overall. These conclusions were sup-ported by an in-depth review of Alliance income and expenditure over the five years from 2006-2011, and an assessment – through documentary reviews, interviews and focus group discussions – of its impact in countries. Measures were also identified to improve cost-effectiveness, and streamline the operations of task forces and work-ing groups. These measures have been taken up in the day-to-day management of Alliance operations (and in the development of the new strategy for 2013-2016).

Tunis in July 2012, attended by the WHO Director General, the President of the African Development Bank, and over 30 ministers of health and finance from the African continent.

The Alliance Secretariat: value for money and cost effectiveness

The Alliance Secretariat has reduced its staffing from 22 approved positions to 14 positions for 2013, in order to enhance cost effectiveness, while maintaining core functions. Additional internal cost measures include: outsourcing of some functions previously performed in-house (such as IT-related functions); reclassification of staff posi-tions in alignment with the 2013-2016 strategy; greater use of web-based member platform for discussions/collaboration (rather than costlier face-to-face meetings); and reduction of travel costs through a revised travel policy.

Membership and partnerships

Alliance members and partners are fundamental to its advocacy initiatives. The Alliance Secre-tariat supports and harnesses the 460+ members’ capacity to directly advocate for adoption of HRH policies, and to leverage the strength of regional health and HRH networks. The 2011 external evaluation recommended better harnessing of Alli-ance member contributions. This recommendation was reflected in the new strategy for 2013-2016, a key principle of which is to mobilize and empower members, partners and stakeholders to increase their participation and contribution. The Alliance developed and launched a new membership e-platform in October 2012 to improve communi-cation with, and the contribution of members. The platform enables Alliance members to share infor-mation on their respective activities, network and collaborate, and participate in online discussions and global consultations. Results include:

40 41





5. Looking forward

> Use in the ‘Community of Practice’ consultation in Cameroon hosted by UNFPA and other UN agencies, in which the Alliance was a partner for an interagency project to tackle and reduce MNCH mortality, pre-dominately in Francophone African countries.

> Sharing views and commenting on the proposed programme for the Third Global Forum.

A mapping of HRH contributions during 2006-2009 from 11 major develop-ment partners in health in the 57 countries with critical health workforce shortages was conducted in late 2011-2012. Results showed that while it is difficult to track full HRH contributions by development partners outside of Organisation for Economic Co-operation and Development (OECD) data (which categorizes HRH data only under education and training, and does not include other HRH components), there is evidence that HRH contribu-tions by some (such as the Global Fund) had increased during the period analyzed.

Budget and finance

The Alliance Secretariat has been funded through donors including Can-ada, European Union (EU), France (AFD: Agence Française de Développe-ment), Germany (BMZ/GIZ: German International Development Agency), Ireland (Irish Aid), Japan, Norway, UK (DFID: Department for International Development), USAID and the Bill and Melinda Gates Foundation. The Alli-ance is now in the process of securing its core funding needs to meet its 2013-16 requirements.

The 2012 annual workplan initially envisaged a total allocation of US$ 6,430,000 (excluding programme support costs). However, adjustments were required in the first and second quarters of 2012, and in the sec-ond quarter, the Alliance Board approved a new strategy, which entailed changes in the strategic focus of the Secretariat going forward.

As a result at the 14th Board meeting in July 2012, a revised budget of US $ 4,749,823 was approved. Adjustments made in the remaining part of the year should aim to position the Secretariat to implement the new strategy.

Table 1. Annual Financial Statement of the Alliance as of 31 December 2012 10

Financialoverview2012 US$

Income

Opening Balance at 1 January 2012 2 202 893

New grants in 2012 (Net of PSC) 3 941 924

TotalAvailableFunds2012 6 144 817

Less

Expenditure

2012 Workplan Expenditures & Encumbrances 4 346 869

Total2012Expenditures 4 346 869

ClosingBalancesat31December2012 1 797 948

10 Adjustment, if any, subject to WHO biennium financial closure (2012-13)

42 43





5. Looking forward

2012WorkplanExpenditure&Encumbrances US$

Objective1:FacilitatingCountryActions

Countries Support

Case Studies - Assessment

Community of Practice Meeting

545 405

39 330

127 448

Sub-totalObjective1 712 183

Objective2:ContinuingAdvocacy

Mainstreaming Human Resources for Health

Communication Products

3rd Global Forum Preparations

147 156

98 092

69 483


Objective3:KnowledgeBrokering

Brokering & Translation

Policy Dialogue on HRH

Policy Impact Assessment Tool

2 000

27 159

20 000


Objective4:PartnerSynergy

Regional Networks

Partners Mobilized

125 494

24 988


Objective5:Oversight&Management

Mgmt Oversight, Operations

Governance & Board Meetings

Staff Costs

38 323

99 832

2 982 159

Sub-totalObjective5 3 120 314

2012TotalGHWAExpenditures&Encumbrances 4 346 869

Table 2. Funding contribution to the Alliance from 2006 to 2012 (December)

Donor FundingfromInception(US$)

Canada (CIDA) 3 436 911

Norway 11 744 753

Bill & Melinda Gates Foundation 5 000 000

European Commisiion 1 771 121

France (AFD) 4 202 420

Germany (GIZ) 2 112 117

Ireland (Irish Aid) 5 198 748

UK (DFID) 5 104 043

US (USAID) 1 445 000

Japan 3 494 000

Total 43 509 113

Japan8%

US(USAID)

3%UK

(DFID)12%

Ireland(Irish Aid)

12%

Germany(GIZ)5% France

(AFD)10%

EuropeanCommission

4%

Bill & MelindaGates Foundation

11%

Norway27%

Canada(CIDA)

8%

Looking forward

to ensure global recognition of its long-term HRH vision that seeks to ensure that everyone has access to qualified health workers, and avoidable morbidity and mortality are eliminated.

The Alliance vision includes greater global col-laboration in embedding HRH in the post-2015 development agenda, and attaining the health-related MDGs and UHC goals. The Alliance will continue to advocate for accountability for HRH results as an integral part of existing health governance and monitoring platforms. Alliance members and collaborators are fundamental to its achievements and its future impact. Thus, the Alliance will support and mobilize HRH stakehold-ers to play a major role in setting and achieving national HRH development priorities and health system strengthening, and developing national HRH strategies and plans, through its core objec-tives (seeBox9).

The Alliance’s work to be undertaken in 2013 will lay the foundations for new commitments to

The HRH landscape remains fundamentally lack-ing in sufficient numbers of, training for, and sup-port to health workers. Many countries have failed to develop, fully implement or integrate health workforce strategies and quality HRH plans within national health services, while political atten-tion has not always led to revised policies and adequate resources for HRH, and private sector potential has not been fully exploited.

The HRH crisis is having a significant impact on countries’ efforts to reduce maternal and child mortality, combat infectious diseases and NCDs, and achieve UHC goals. Critical work is needed, and through its new strategy for 2013-2016, the Alliance is well-placed and equipped to anticipate and respond to HRH challenges, and move forward the HRH agenda. The Alliance will step up its efforts to mobilize resources, and secure support to improve the capacity of the health workforce, and advocate for at least an additional two mil-lion health workers to be trained, deployed and retained in support of UHC. The Alliance will work

advance HRH, to embed an HRH dimension into early discussions on the post-MDG development framework, to accelerate the development and implementation of health workforce strategies as part of national health plans, and to establish a framework for mobilization and mutual account-ability among members, partners and HRH stakeholders.

The Alliance’s mandate remains to play the leader-ship role in increasing access to, and improving the capacity of health workers to deliver effective health services, as a precursor to UHC. However, the new strategy represents a new approach. The Alliance will direct its policy advocacy efforts towards ensuring that the centrality of HRH to UHC and to the post-2015 health agenda is recognized. Implicit in this key point is that the HRH crisis is not limited to the 57 previously identified coun-tries with chronic health worker shortages. The HRH crisis exists in low-, middle- and high-income countries, and which relate to distribution, quality, competence, motivation and performance, as well

as mere numbers. This point is fundamental in ensuring that the UHC and post-2015 development agendas pay specific attention to HRH challenges.

The ‘Third Global Forum on Human Resources for Health’ to be held in Brazil in 2013 is a key event for HRH and strengthening health systems. The Forum theme (‘Human resources for health: foundation for universal health coverage and the post-2015 development agenda’) represents an important opportunity to establish HRH in the post-2015 development framework, promote uni-versal health coverage, and achieve binding HRH commitments from countries, agencies, partners to advance the HRH agenda.

The Forum is expected to attract over 1,500 par-ticipants, including heads of state, ministries of health and finance, leading civil society organiza-tions, international HRH experts, health profes-sionals and health workers, researchers and policy makers.

4646 47

ThreecoreobjectivesoftheAlliances’strategyfor2103-2106 Box8

1. Enablingsolutions: Promote the adoption of coherent policies and investment decisions through

advocacy to strategic constituencies and by stewarding a global HRH agenda. 2. Catalyzingactions: Foster interaction for more effective HRH coordination, policy dialogue and actions

across different sectors and constituencies in society, including government and private sector, civil

society and professional associations.3. Ensuringresultsandaccountability: Monitor and report on HRH developments and commitments

through a process of accountability underpinned by cutting-edge intelligence and analysis.

Keyresultsfor2013contributingtotheAlliance’svision Box9

> Policy recommendations on appropriate HRH strategies and priorities for universal health coverage

developed and considered within relevant policy dialogue on the post-MDG agenda; > Partners mobilized in over 20 countries to provide support for the development and implementation

of evidence-based quality HRH plans, fully embedded in national health strategies, in support of the

achievement of the UN Global Strategy for Women’s and Children’s Health, and the Muskoka Initiative;> HRH coalitions supported in three countries to strengthen capacity at national level for greater inclusivity

and responsiveness of national HRH efforts. > HRH mainstreamed in proceedings, political declarations and commitments of key global and regional

health and development events;> A ‘Third Global Forum on Human Resources for Health’ convened to advance the HRH agenda, and elicit

new HRH-related commitments.

48

Launched in 2006, the GlobalHealthWorkforceAlliance is a partnership dedicated to iden-tifying and coordinating solutions to the health workforce crisis. It brings together a variety of actors, including national governments, civil society, finance institutions, health workers, international agencies, academic institutions and professional associations. The Alliance is hosted by the World Health Organization.

Forfurtherinformation,pleasecontact:

GlobalHealthWorkforceAllianceWorld Health OrganizationAvenue Appia 201211 Geneva 27SwitzerlandTel: +41 22 791 26 21 Fax: +41 22 791 48 41Email: [email protected]: www.who.int/workforcealliance

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