Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM and PEPFAR-funded HIV-activities

Relevant features of the 5 countries studied are presented in Table 2. All 5 countries now have democratically elected governments, though most are relatively new multi-party democracies, including South Africa and Mozambique (1994) and Burundi (2005). Burundi gained independence in the 1960s, whereas Angola and Mozambique did so in 1975. These 3 countries have experienced civil wars, Mozambique just after its independence and more recently Angola and Burundi. In terms of demography, Burundi is an outlier, with 318 inhabitants per km², whereas other countries’ densities range from 15 to 71 per km². South Africa is an upper-middle income country, Lesotho and Angola are lower-middle income countries and Mozambique and Burundi are low-income countries (World Bank classification 2009). The position of the 5 countries within this classification was correlated with the amount of Official Aid for Development as % of Gross National Income: Burundi and Mozambique are the 2 countries most dependent on external aid.

With regard to health financing, all governments spent in 2009 from 8 to 13% of their total expenditure on the health sector; this percentage included funding from external sources. The latter represents as much as 72% for Mozambique, 45% in Burundi, and 30% in Lesotho, but only 3 and 2% for Angola and South Africa respectively. If external sources of funding are excluded, government expenditure on health would drop significantly in the 4 first countries, and would then represent less than 7% of total government expenditure.

The health system organization is typically pyramidal in all countries, with a centrally managed district-based system. In Burundi, decision-making remains very centralized at national level, especially budget allocation, since the district health system is very recent. In South Africa, the national level plays a normative role, by drafting policies and allocating funding, while provinces have considerable autonomy and exhibit variation. In Angola, the national level has a normative role and since 2007, municipal health authorities are in charge of district health management (including budget allocation) and planning. In Mozambique and in Lesotho, the decentralization process has been gradual. In Mozambique, provinces gained autonomy, while budget allocation is still centralized. All countries have HRH development policies and plans, but their level of ownership and sophistication varies: South Africa’s plan is relatively detailed with projections of HRH until 2025 [16]; Mozambique’s is clearly articulated with MDGs and aligned with other policies but lacks funding (National Plan for HRH Development 2008–2015; National Directorate of Human Resources, Ministry of Health, 2008); whereas Burundi launched its first plan only in 2010 [17]; Lesotho’s HRH policy is clearly articulated with the Health and Social Welfare Policy (2004) which ensures appropriate supply, and properly trained personnel to meet the needs of the country and also ensures career development.

In terms of HRH quantity, all countries except South Africa have experienced a general HRH deficit [18]. However, these figures are aggregates, neglecting the breakdown between public and private for profit (PFP) staff. In South Africa, the PFP sector is favoured by physicians, with 59% of them working in this sector in 2010, while serving only 15% of the population [19]. In the other 4 countries, the PFP sector is not so prominent, though its assessment is difficult, since many HRH working in the public sector are in dual practice, undertaking a parallel PFP activity. If only the public sector is considered and the threshold of 2.3 health workers (0.55 doctors and 1.88 nurses and midwives per 1,000 population) applied, all 5 countries have unmet needs, both in 2004 and 2010 (Figure 1). The extent of unmet needs in the public sector varies, with the lowest density of physicians and professional nurses in Burundi and Mozambique, whereas Angola has a shortage of physicians and has nurses in excess (though most of them have only basic level education) when compared to the WHO threshold.

Since at least 2004, all 5 countries have been receiving funding from the 3 GHIs (GFATM, PEPFAR -except for Burundi- and the World Bank MAP -except for South Africa-).The amounts disbursed by PEPFAR greatly outweighed those of GFATM and MAP, especially in South Africa and Mozambique (Table 2), much of it for ARV roll-out. Lesotho was not a focus-country for PEPFAR and Burundi was not eligible for PEPFAR until 2011. In terms of subsequent ARV roll-out, the increase in the number of patients on ARV was dramatic in all 5 countries between 2004 and 2009 (Table 3), despite the sustained deficit in HRH (Figure 1). The majority of patients were enrolled for ARV in the public sector, except for Burundi where the majority were initially enrolled in stand-alone HIV-clinics run by local NGOs. Data from our study showed that this successful ARV roll-out, despite a HRH deficit in these countries, was a result of adaptive practices, which occurred in a similar way in all countries: initially, a short-term emergency response mostly by GHI-funded NGOs and to a lesser extent by government; then, challenges related to this emergency-type response increased and, as HIV became a chronic disease, government started to formulate and implement long-term policies, sometimes in collaboration with GHIs. This 2-step country-response is detailed below.

In all countries, funding from GHIs provided a substantial amount of money, usually with a clear conditionality related to quantitative targets achievement, to kick start the disbursement of the next financial tranche [21]. This mechanism of funding was new, placing significant pressure on country systems and accountability. This pressure contributed to the creation of parallel HIV units to enable M&E reporting to GHIs, and to allow targets to be reached quickly [9]. The necessity to quickly reach such targets, led to recruitment and training of HRH, who were retained using incentives. Recruitment however occurred only in a limited number, due to the restricted funding amount. The creation of vertical programs was seen to be justified by the sense of emergency, generated by a series of high level global policy meetings around 2001–2002 in response to the growing HIV epidemic in SSA. It probably also served to demonstrate the effectiveness of certain types of funding over others, thus fuelling pre-existing competition between agencies at global level [34]. In addition to the workload added by HIV care, the combination of preventative and curative care that GHIs funding was meant to deliver was new to public sector facilities, and GHIs proposals were an open call to NGOs and civil society participation [21]. This partly explains the extensive use of NGOs (local and international) as short-term strategies to overcome the HRH crisis, either by seconding their staff to facilities, or by creating stand-alone NGOs for HIV care. In addition to these explanations above, which influenced certain types of short-term HRH strategies over more long-term ones, each country reflected its specificity, according to its historical and political background.

In South Africa, the health system in the pre-GHI era was already sufficiently organized relatively to the 4 other countries. On the one hand, this allowed secondment of NGO staff to public sector facilities, according to a pre-defined agreement. On the other hand, the very hierarchical and managerial functioning of the South African health system did not immediately allow a clear task-shifting model to be implemented at facility-level. NGOs were the most innovative in this domain, testing several models of care in different facilities.

In Burundi, Lesotho and Mozambique, a parallel implementing agency, separate from the Ministry of Health, was created to manage funding from GHIs. Furthermore in Burundi, a separate Ministry of HIV/AIDS was created. Such separation between health and so-called HIV sectors, while facilitating the daily management in the short-term, created inequities in treatment between HIV-dedicated and general staff. Also in these 3 countries, the use of CHWs was well accepted, since rural areas have relied on them for decades, especially during times of civil war. In Angola, no task-shifting was employed at facility level, nor were HIV units created, possibly related to a relatively low prevalence of HIV in the country.

As challenges and limits of short-term HRH strategies were revealed, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives (new cadre of health workers, task-shifting), increase in HRH production, and mitigation of internal migration of HRH, by increasing public HRH salaries or by imposing salary alignment on NGOs.

Content of HRH strengthening policy differed, according to, inter alia, countries’ financial and political resources and to their resultant degree of dependence on external donors. Thus, South Africa and Angola could more easily create new cadres of health workers since these governments had sufficient funds to devote to indigenous training institutions and to increase production of HRH. Some countries, such as Burundi, did not have the negotiation space to impose a code of conduct on NGOs (i.e. to set a salary scale). Such policy space depends significantly on the extent of reliance on external donors, including NGOs. Burundi preferred to increase public sector salaries instead, which was already a pressing issue. South Africa managed to impose an anti-poaching agreement on NGOs and both Angola and South Africa managed to force NGOs to align their salaries with public sector salaries. The Mozambique government forced to align salaries of NGO staff seconded to public sector facilities with those in the public sector, but did not have any control over salaries of NGO staff per se.

Countries also implemented HRH strengthening policies, independently of GHIs: in Angola, South Africa and Burundi, governments started to sign bilateral agreements with countries which have a surplus of HRH, such as Cuba (for South Africa, though this pre-dated GHIs), China and Egypt (Burundi). In all countries except Angola, governments implemented incentive schemes for rural areas and sometimes retention schemes for undersubscribed specialties, independently of GHIs. In South Africa, the national department of health introduced increased remuneration to some categories of public sector HRH to reduce external or internal migration ('occupational specific dispensation’). Medical interns are also required to perform community service for 2 years in rural areas. In Mozambique, health workers working in remote rural areas are allocated an “isolation subsidy” which increases with remoteness of the placement. In Lesotho, to increase rural coverage, public sector nurses are mandatorily sent to rural areas for a period of 2 years (national policy in place since before GHIs). Also, some faith-based organizations, mostly located in rural areas, provided lower salaries than government and hence are being subsidized by government. The government, with donor support, recruited nurses from Kenya and Zimbabwe to work in some of the health facilities in the remote areas. Since 2006, in Burundi, medical doctors need to spend a 2-year mandatory period in the public sector, mostly in rural areas, if they wish to specialise.

GHIs and governments increased their collaboration and GHIs reshuffled their scope of activities in order to fit the HRH strategies at country-level, following the Paris declaration and acknowledging the need for aid effectiveness and increased coordination. GHIs started to take HRH pre-service trainings into consideration, although production was not initially their concern. PEPFAR for instance launched the MEPI and NEPI in 2010, two programs aiming at strengthening pre-service training of HRH [35].

Whether these changes were induced by repeated criticisms of GHI’s targets which were predominantly aligned to short-term objectives, such as short-courses and in-service trainings, has been a subject of debate [36]. Attribution to one or other cause is not possible and these changes were probably a result of a mixture of events and influences: GHIs were evaluated through a pre-set mechanism (i.e. 5-year GFATM evaluations for GFATM) [21], and further analysed via independent or commissioned research; many of them emphasized the fragmenting effects GHIs were having on the health system and in particular on HRH [9, 11, 13, 37‐39]; external advocacy towards more focus on HSS and against “AIDS exceptionalism” also grew, through conferences and publications; a global HSS debate was complemented by a focus on long-term HRH production [40].

As countries’ responses to HRH challenges were reported to GHIs, some of these, such as GFATM and Global Alliance for Vaccines and Immunization (GAVI), with a participative approach, allowed criticisms to be partly addressed in a timely manner: GFATM in 2005 introduced a HSS section to their funding application and GAVI-HSS was launched in 2006 in pilot countries [41]. Other GHIs, such as PEPFAR, more rigid in its functioning and administration, also took into account such criticisms, but at a slower pace and in a more contained way [22, 42]. The slow shift to more sustainable, indigenous responses towards HSS and especially HRH strengthening seems therefore a result of a dialectical relationship between GHI-driven initiatives and country responses, while the shift has also been impelled by other objective changes (e.g. availability of generic drugs). Reduction in global funding is also certainly forcing countries and GHIs to invest more in long-term action, such as pre-service training, better coordination of training, collaboration across sectors through partnerships or across programs (TB-HIV, HIV-reproductive health) and equity in salaries.

While GHIs should be commended on their genuine efforts to improve countries’ health system, whether these HSS plans are really strengthening or just supporting the health system is a matter of debate [43]. Also, an ideological struggle seems to have arisen around whether GHIs have de facto strengthened health systems or had the opposite effect [44‐48]. Answers to these questions will influence future HSS directions for GHIs and countries and caution is needed in interpreting them, since answers might differ depending on who the assessor is and what meaning is given to “HSS”. Suggestions for a new orientation of GHIs have started to emerge based on accumulated country-based experience and other complex factors [49].

GFATM and GAVI have both included in their funding programs a stream for HSS, but results have been mixed: GFATM interrupted its HSS program a year after its launch, due possibly to a lack of clear definition of HSS [50]. No clear objective for HSS has been set and each program has been left to strengthen its own system. GAVI-HSS programs have not taken into account sustainability: for example in Burundi, the GAVI-HSS funds were used inter alia to pay for fuel and salaries for drivers, in order to transport pregnant women to referral hospitals. Also, initially, an item for HRH capacity strengthening existed in all GFATM proposals, but these were mainly interpreted as in-service training by recipients or used to hire extra staff, without a clear sustainability plan. Some of these HRH are now left without a secure position since GHI funding has shrunk.

Similarly, the MEPI and NEPI are projected as examples of PEPFAR platforms for strengthening the sustainability of HRH in the countries [22] though the majority of funding is still clearly earmarked for expanding HIV management and HIV research capacity [31]. The non-coordination between GHIs at global level, impacting negatively coordination at country level, has also emerged as a common feature to all countries, in our example of HRH strategies. In an attempt to respond in a coordinated way to health system challenges, a project to develop a joint HSS funding platform between the World Bank, GAVI and GFATM was launched in 2009 [51, 52]. However, the project has stalled, showing, inter alia, the extent to which an agreement on HSS objectives and visions is difficult to obtain [53].

Our study has some limitations.

Qualitative data were collected in a cross-sectional,manner with different time-periods (Table 1), rising issue of temporal bias while comparing findings.

Quantitative data proved difficult or impossible to compare, since HRH categories were not the same across countries, and data were not consistently available or complete for the same time periods. The numbers of HRH specific to HIV were not available; nor were the distribution of HRH according to NGOs/private/public sector. Hence, quantitative data were provided solely for an illustrative purpose and do not serve as a basis for a rigorous statistical comparison. Information on non-response rates to requests for interviews was not available consistently across the 5 countries and was therefore not presented. This could have contributed to an ascertainment bias.

Some important institutions such as professional councils were not interviewed at first, or, even when solicited, did not reply (Health Professionals Council in South Africa). This constitutes a limitation given the role that professional councils play in HRH policies.

Particular policies adopted to counteract a specific effect induced by GHIs were difficult to distinguish from more general policies adopted by the government to address the overall HRH crisis, which pre-dated GHIs.

Finally, given the open nature of the health system, attribution of changes to the influence of GHIs or activists/researchers or countries is an impossible task (and probably not useful). The truth probably lies somewhere between these different interpretations, where stream of influences mix with experiences and beliefs and create a general direction that actors tend to follow and refine through compromise and consensus. This last point refers directly to the inherent complexity of the field of health policy and system research, constantly influenced by political and social dynamics [54].

Despite these limitations, we believe that this study provides a unique insight into the complex and slow process of policy shift which has occurred in five countries, between 2007 and 2011, using the example of HRH policies and their evolution in response to GHIs and related HIV activities. Collectively, the findings point to some consistent patterns and effects of GHIs on HRH policies and the workforce, as well as some context-specific differences, across these five southern African countries.