Global Fund financing and human resources for health investments in the Eastern Mediterranean Region

The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) was founded in 2002 to accelerate the end of the epidemics of these devastating diseases in low- and middle-income countries (LMICs) [1]. The organization also seeks to strengthen health systems in countries through direct health system strengthening investments and indirectly through investing in interventions across the three diseases. An important area of investment is human resources for health (HRH), which the World Health Organization describes as one of the six core components or “building blocks” of health systems [2]. Many LMICs, especially those in areas with recent conflicts and instability, face critical HRH challenges including health worker shortage, geographic maldistribution and migration, skill-mix imbalance, weak regulation, poor work environment, and poor quality and limited capacity of educational and training programs [3‐6]. Increasingly, it is acknowledged that the health workforce availability and quality are critical in the implementation of externally funded projects, such as those funded by the Global Fund.

Since its inception in 2003, the Global Fund has invested over US$40 billion in over 100 countries to combat human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis (TB), and malaria [1], with a certain percentage of this allocated to HRH-related activities, depending on the country and its needs. A study of 138 Global Fund recipient countries estimated that around US$1.4 billion (23% of total US$6.2 billion) was allocated to HRH-related activities between the first and seventh round of funding over the period 2003–2008 [7]. Global Fund investments strengthened health workforce in recipient countries through funding short-term and in-service training, as well as innovative remuneration of health workers [7‐10], though investment in HRH was mainly limited to in-service training and supporting program management staff [8]. Other studies suggest potential unintended negative consequences of disease-focused investments in human resources through the displacement of health workers to funded programs to the detriment of adequately staffing other health programs [11‐13].

This study builds off the limited existing research on how HRH has been influenced by donor investments in LMICs [7]. The aim of the study is to examine the specific role of the Global Fund in strengthening HRH in the Eastern Mediterranean Region (EMR). The EMR in this context are 21 countries and territories served by the World Health Organization (WHO) Regional Office in the Eastern Mediterranean. This region, prone to tension and conflict, has one of the lower overall HRH densities among the six WHO regional groupings [4, 5, 14]. As of 2018, 8% of total investments by the Global Fund have been in North Africa and the Middle East, the third largest behind Sub-Saharan Africa (65%) and Asia and the Pacific (19%) [15]. In addition, there has been minimal investigation of the role of such investments in improving HRH in this region. Our research questions are as follows: (1) What are the levels and composition of Global Fund investments in HRH in EMR countries? (2) What types of HRH activities have been supported by these investments? and (3) In what ways have these investments contributed to health system strengthening in some of these countries?

To answer these questions, we examine the Global Fund financing for HRH across those EMR countries that received Global Fund grants. We then focus on two of these countries in more detail to understand the types of HRH activities supported and contributions to health system strengthening. This study adds to the policy dialogue on the role of global health initiatives in improving HRH, and by extension health systems in LMICs, especially in the EMR.

The analytical framework used in this study, as shown in Fig. 1, was adapted to the EMR and was used to guide the methods and analysis for this research [7]. The magnitude of Global Fund HRH investments in EMR countries over the period 2003–2017 was tracked and captured. Global Fund investments were linked to specific HRH activities which were in turn associated with potential HRH outcomes and health systems strengthening.

We employed mixed research methodology comprising both quantitative and qualitative analyses in three main phases as illustrated in Fig. 2 [16]. Phases 1 and 2 involved utilizing quantitative methods to examine the magnitude of HRH investments as well as compositions by income group, disease focus, and Global Fund regional team categorizations. The results from phases 1 and 2 were then complemented in phase 3 with case studies of selected countries in the region (Afghanistan and Sudan). The key outputs examined were training- and human resources (HR)-related outputs, such as HR financing (salary support, performance incentives, for example), hiring, and recruitment [7].

In phase 1, we analyzed budgetary and expenditure data for the 13 EMR countries that had received Global Fund grants using data from the Global Fund Enhanced Financial Reporting System over the period 2003 (Global Fund inception) to 2017 (the last year of complete data before analysis was conducted). These countries were Afghanistan, Djibouti, Egypt, Iran, Iraq, Jordan, Morocco, Pakistan, Somalia, Sudan, Syrian Arab Republic, Tunisia, and Yemen. This analysis examined the total aggregate Global Fund investments in each country and lower-level investments in human resources, training activities, and technical assistance. We also analyzed the compositions of these investments by disease categories (HIV/AIDS, TB and malaria), by income groupings (based on 2018 World Bank income classifications) [17] and Global Fund regional team categorizations in the region. The budgetary and expenditure data provided high-level aggregate summaries for the four main cost categories: human resources, training, technical assistance, and “other”. “Other” category was comprised of non-HRH-related cost categories such as “medicines and pharmaceutical products,” “monitoring and evaluation,” “overheads,” “planning and administration,” “procurement and supply management costs,” “infrastructure and other equipment,” and “health products and health equipment.” These categories were based on Global Fund reporting requirements and guidelines [18] and were a result of high-level aggregates across the funding models they used, namely the round-based system (2003-2013) and the new funding model (2014 until current date). It was not possible, due to data limitations within the Global Fund reporting system, to obtain disaggregated and more detailed data within these high-level aggregates over the period of 2003–2013. With the new funding model, data available after 2015 did incorporate more detailed and disaggregated cost categories. Total amounts budgeted and expensed for training and human resources were examined as well as the percent of these amounts in comparison to total Global Fund budgets and expenses across the years of funding. These percentages were also examined over time, using the time periods 2003–2007 and 2008–2017 to compare to a similar analysis done prior to 2007 [7].

For this reason, in phase 2, we tracked and documented spending within the cost categories using more detailed budgetary data acquired from the Global Fund over period 2015–2017. This data set provided budgetary sub-categories (cost groupings) for three main HRH-related cost categories: human resources, travel-related costs (TRC) formerly referred to as training, and external professional services formerly referred to as technical assistance. The cost groupings under these cost categories were as follows (Table 1): human resources: salaries (program management), salaries (outreach workers/medical staff), and performance-based supplement, and other human resources costs; travel-related costs (TRC): training-related per diems/transportation/other costs, technical assistance-related per diems/transportation/other costs, supervision/survey/data collection-related per diems/transportation costs, meeting/advocacy-related per diems/transportation/other costs, and other transportation costs; and external professional services: technical assistance fees/consultants, fiscal/fiduciary agent fees, external audit fees, and other external professional services.

All other sub-categories or cost groupings which were not direct investments in local human resources for health in a country were classified as “indirect” HRH costs. For example, under human resources, the sub-category designated as salaries (program management) captured funds allocated by Global Fund to pay salaries for the managers within organizations (principal recipients) that administered the grants. These allocations were not direct investments in health cadres that provided clinical services and hence were not considered direct human resource strengthening investments for the purpose of this study.

According to the framework of this study, direct investment in HRH was captured through allocations that most directly impacted the hiring and training of service providers (clinical cadres). We identified cost groupings within human resources, training, and technical assistance that most clearly overlapped with hiring and training. These were called direct HRH financial investments in this study (Table 1). These direct financial investments were those in the top panel in Table 1: “salaries (outreach workers/medical staff), and performance-based supplement” [under human resources]; “training-related per diems/transportation/other costs” [under TRC], and “technical assistance fees/consultants” [under external professional services /technical assistance]. We calculated the percent of the total budget as well as the percent of each cost category (human resources, TRC, and external professional services/technical assistance) that were allocated to these direct HRH investments. These percentages were referred to as direct HRH budget allocations and served as lower bound estimates within the upper bound estimates that captured the total proportion of Global Fund HRH investments in human resources and training.

In phase 3, two countries—Afghanistan and Sudan—were selected from the region for case studies, taking into consideration the variation in Global Fund financing for human resources, density of human resources, and feasibility of conducting key informant interviews across the 21 EMR countries. The case study methodology involved a desk review of Global Fund grant proposals and performance reports as well as sending an interview form to agencies and programs that had been involved in the Global Fund programs in each country. The interview form collected qualitative information on training and human resource investments made with Global Fund financing. Follow-up meetings and/or phone calls were held with focal points from the agencies and programs to verify information from the interview form. All responses were voluntary, and respondent answers were de-identified for the analysis to ensure confidentiality and anonymity. A total of 14 focal points were interviewed from 10 key agencies/programs in Afghanistan and Sudan. The case study results focused on activities related to grants that were active between 2015 and 2017.

A total of 13 countries from the Eastern Mediterranean Region who were previous and current grant recipients are included in this study. Of these 13 countries, nine were funded during the study period. Four countries were not funded as of 2018, but had received grants in the past. About half of these countries were in the World Bank lower-middle-income category (Table 2) [17]. With respect to HRH density, Global Fund recipient countries have physician and nurse/midwife HRH densities below the regional average in the EMR region, based on the most recent data available.

We find that approximately 27–28% of Global Fund’s 2003 to 2017 total budgets and expenditures are allocated to HRH in this region (as reported in Table 3 and Fig. 3). This is greater than the global average of 23% estimated by Bowser et al. (2014) as being allocated to HRH in their review of Global Fund investments across 138 recipient countries between 2003 and 2007 [7]. However, as shown above, the amount budgeted and expensed for HRH as a percent of total Global Fund financing has increased over time in the EMR, possibly reflecting the increased priority placed on health systems strengthening by the Global Fund within the three disease components of this study and separately through the HSS/RSSH component.

Our analysis of direct estimates of HRH budgets between 2015 and 2017 provides a more in-depth examination of budgetary allocations to those cost groupings that most “directly” support HRH in each country. The direct analysis suggests that only about a third of allocations to HRH (averages of 13% [direct HR] compared to 36% [total HR] between 2015 and 2017) directly impact local health workers. This is an especially important finding, as it helps provide a more accurate picture of HRH investments which could be overestimated when payment to employees of in-country contractors who manage the Global Fund grants are also included. These results are not meant to suggest that funding for grant and program management is not important, but to stress the importance of having an accurate measure of funds that directly support healthcare workers in Global Fund countries [10]. This level of disaggregation is only possible for the most recent years of budgeting (2015–2017) due to significant improvements in data collection and feedback between recipient countries and the Global Fund. In addition, a more disaggregated analysis is only available for budgetary data and not expenditures. Expenditure data would provide a more accurate depiction of spending on in-country HRH supporting activities.

Global Fund has supported pre-service and in-service trainings in both Afghanistan and Sudan. In Afghanistan, the pre-service training programs have been useful in increasing the number of health workers, as well as addressing the gender imbalance in HRH shortage. This is particularly important in this setting where cultural barriers prevent female patients from accessing health care from male health workers. In Sudan, Global Fund support for pre-service training has been channeled through funding of infrastructure needed to train health workers. Investment in pre-service training in both countries is noteworthy because previous research found that global health initiatives such as Global Fund’s HR investment is mainly focused on in-service training [8‐10]. Noting the downward trend in nurse densities in both countries over time and more generally the low HRH densities in recipient countries (Table 2), a reduction in this imbalance between in-service and pre-service training investment can help begin to address critical health worker shortage issues. In-service training programs focused on integrating care also have potential to reduce fragmentation and improve delivery of care in these countries [21]. In addition, some of the training programs, such as the Academy of Health Sciences, demonstrate a degree of institutionalization whereby the establishment and implementation of a training center is driven by local officials while being supported by Global Fund investment. However, concerns remain about the continued quality and operation of these centers and programs at the end of Global Fund financing.

Human resource investment includes salary support in terms of top-ups and performance incentives, as the Global Fund does not directly pay health workers’ salaries in the two countries, except the program management staff at the national level. This might mitigate to some extent concerns related to sustainability, health worker motivation, and displacement found in previous studies [9, 12, 22]. However, it does not address the limited capacity of the health ministries to absorb and assimilate newly trained health workers into the public health sector. The “direct” HR budgetary allocations in Afghanistan (14%) and Sudan (10%) at the time of the study suggest that there is room to increase these allocations in order to scale up health workforce to achieve a sustainable health workforce for the future, including investment in production capacities. The low health workforce densities, coupled with limited employment capacities and lack of incentives to retain health care workers, implies the need to consider increasing investment in health workforce to ensure the delivery of services, commodities, and building health workforce as countries graduate from Global Fund's support.

There is evidence of close coordination between Global Fund investments in HRH and relevant departments and stakeholders in Sudan. The creation of the “One Plan” initiative is an example of a proactive approach to ensuring coordination and harmonization between external donors, local implementers and the Ministry of Health. This approach can be adapted to other contextual settings as a potential way of addressing the issue of poor coordination among stakeholders reported by other studies (e.g. [7, 9, 11]). However, we find a gap in the level of coordination between grants, government agencies, and principal recipients (grant managers) over time. This gap may only be effectively bridged by the recipient country governments ensuring that knowledge, lessons, and information from a grant are carried over to the next grant and thus build institutional memory. While not directly analyzed as part of the study, having two HSS/RSSH grants in Afghanistan and one HSS/RSSH grant in Sudan (three HSS/RSSH grants in total across both countries) suggests a focus on system strengthening in addition to disease-specific programs.

This study provides new insights into EMR Global Fund investments from its onset until 2017 and also serves as an update to a previous study that used similar data from 2002 to 2010 [7]. There are, however, some limitations that highlight the challenges and complexity of tracking large-scale investments such as those described in this study and understanding their impact on recipient countries. First, available data on expenditure were not disaggregated to a level that linked monetary amounts to specific training and HR activities. Hence, the high-level aggregates of the proportion of HRH budget and expenditure allocations from 2003 to 2017 may be overestimated, as they include line items such as salaries of organizations managing the grants in recipient countries.

Another, data-related limitation is that we are not able to evaluate the impact of Global Fund investment on health outcomes in recipient countries, which would be a potential next step in further elucidating the effect of Global Fund HRH investments in recipient countries. In addition, it was only possible to collect in-depth data on two country case studies. Additional case studies could have enhanced the qualitative nature of the study.

This study presents new evidence on the magnitude and composition of Global Fund’s HRH investments and the HRH-related outputs in the EMR. Analysis of high-level aggregate data between 2003 and 2017 finds that about a third of Global Fund budget and expenditure goes to HRH in this region according to the overall analysis using Global Fund-defined budget lines, while analysis of more recent detailed data between 2015 and 2017 suggests a more conservative estimate of about 13%. In addition, Global Fund investments are being used to support outputs such as pre-service and in-service training as well as salary support such as top-ups and performance incentives. There appears to be clear examples of Global Fund investments contributing to sustainable and institutionalized HRH outputs and some donor coordination in the two case countries. These findings suggest a need for improved information management systems to better track HRH expenditure and key HRH outputs. HRH remains a key issue in strengthening the health system of LMICs and even more so in areas of the globe prone to tension and conflict. Considering the unique HRH challenges in this region, this study indicates a need to continue investments in HRH and analyses of this topic.