Introduction Technical 1 Guidance for Global Fund HIV Proposals Human Resources for HIV/AIDS In the context of this text, the term Human Resources for Health embraces all persons, with or without formal training, who contribute to the protection and improvement of health. This includes all health workers, whether they are employed in the Government service, Non-Governmental Organizations or the private sector, whether self employed or volunteers. It also includes members of communities and households, who, rather than being passive recipients, actually are the main producers and guardians of health. Human resources are the single the most costly element of any health budget, usually consuming 50%, and often considerably more, of the total recurrent expenditure on health. Development of human resources for health for scaling-up HIV/AIDS services towards universal access needs to focus on those elements of the WHO package of priority HIV/AIDS interventions that rely heavily on health care providers, as listed in annex 1. In its most simple form the human resource development process deals with 3 elements some of which require specific action from the standpoint of service delivery for HIV: 1. Supply Supply deals with maintaining / expanding the pool of the active health workforce actually available for the delivery of services. Training and educating new health workers of the right mix of skills and qualifications are only one of the aspects of supply management. Moreover, expanding of basic training capacity and intakes will take many years before a change in supply is noticeable. Ensuring adequate HR supply for scaling up of priority interventions for universal access should therefore primarily rely on methods with a more immediate effect such as recruiting and retraining unemployed or retired health professionals on contract. Ensuring adequate supply also includes measures to attract and retain health workers (e.g. to re-migrate and to be re-employed), and tapping reservoirs of alternative human resources (such as community members, PLWHA, and peers to reach vulnerable groups such as sex workers, men who have sex with men and drug users); Maintaining the pool of active health workers also includes actions to reduce losses for instance by providing HIV positive health workers with ARV and by general personnel management measures such as increasing retirement age. 1 Any technical suggestions or questions about this paper can be addressed to Dr. Eileen Petit-Mshana at petitmshanae@who.int or Dr. Mazuwa Andrew Banda at bandam@who.int 1
Ideally HR supply should match requirements in the long term; this is the domain of strategic HRH planning and computer models are available to assist this specialized process. 2. Deployment In simple terms deployment means ensuring that the right people with the right skills and motivation are in the right place at the right time. Equitable distribution of health workers is very difficult to achieve. Methods used to induce health workers to work in underserved areas include hardship allowances, rotation schemes, recruiting future health workers from underserved areas, bonding schemes, decentralization and other measures, none of them convincingly successful. It is however observed that cadres with lower educational qualifications are usually more equally distributed than those with higher qualifications. Shifting a task from a medical doctor to for instance a clinical officer would therefore make the service resulting from that task more equitably accessible. 3. Productivity Enabling available human resources to perform by giving them the required tools and supplies motivating, training and supporting them to spend their energy on priority interventions supported by evidence, organizing the health system so that it works as a learning organization ; In addition to these three main elements the Human Resources for Health process needs to be supported by 4. Policies, strategies and plans that are based on evidence 5. Evidence from operations research and information systems 6. Organizational structures that clearly delineate mandates and areas of responsibilities in a field with many actors 7. Appropriate legislation 8. Quality assurance 9. Good leadership, management and partnership Formulation of GFATM request for HRH development With a clear picture of the HR availability and requirements of human resources for identified HIV/AIDS priority interventions, the following fields in HRH Development could be considered for inclusion in the GF application, taking care that they are (1) clearly supporting the priority interventions and (2) in line with and supporting national H R H p o l i c i e s a n d p l a n s, s u s t a i n i n g h e a l t h s ys t e m s s t r e n g t h e n i n g : 2
HRH Development Element HR Activity Useful Examples for HIV/AIDS priorities 1. Supply Pre-service training Development of training programs, support of health training institutions, curriculum development, development and distribution of training materials, teacher training. 2. Deployment in difficult jobs, hardship areas 3. Increase productivity Hiring and contracting of staff Community involvement Post-basic Education and Training Sponsorship of individual students Promote working in the HIV/AIDS sector, Fund advertisement Fund staff recruitment process If budget ceilings exist, develop proposals for getting a waiver, hire staff on temporary contract, outsource the hiring of staff to help out where staff are/will become overwhelmed during scale up for universal access Provide allowances, direct specific peer group activities, training & supporting CHWs for scaling up HIV/AIDS services. Facilitate involvement of community members in the planning of HIV services (e.g. stipends to prepare for and attend management meetings, support for community organizations engaged in service delivery for HIV, or in governance of health sector work) Sponsorship of post-basic education and funding of research proposals for carefully selected courses, research and individuals. Motivation Where HIV/AIDS related activities for scaling-up increase the workload, monetary and non-monetary incentives, topping-up of salaries, allowances, job aids, sleeping facilities for staff on duty can be considered Mentoring, counseling Safety and protection at workplace / HWs access to HIV/TB prevention, testing, treatment, care & support Mentoring and counseling will support those working under difficult circumstances and help prevent burn-out Activities improving the protection of health workers including self testing and care for sick health workers and their family; Advocacy, dissemination and implementation of existing guidelines; Insurance schemes for health workers and other measures to assist health workers to take care of their own health and to mitigate the financial impact of illness. In-service training In-service training methods include running and sponsoring candidates to institutional and distance or net-based courses, Development of new courses and course materials, e.g. based on WHO recommended approaches such as IMAI, Organization of workshops and seminars through a decentralized system using a cascade approach Work reorganization Task shifting from scarce to more numerous cadres Balanced distribution of work loads 3
HRH Development Element 4. Human Resources for Health Policy and Planning 5. Evidence for HRH 6. Organization structures 7. Appropriate legislations 8. Quality Assurance 9. Leadership management and partnership HR Activity Useful Examples for HIV/AIDS priorities Logistic support Facilities designed for easy work flows Availability of required equipment and supplies HR Policy and plan Influence and develop amendments to HRH policies to cater influence for HIV/AIDS priorities; e.g. task shifting. Determine HRH staff requirements for inclusion in national Research / information systems HRH plans and budgets Operations research, (e.g. on implementation and impact of task shifting) Strengthening of information systems Improving exchange and access to HR information Links Appoint and support HR focal point in HIV / AIDS Department Review / adapt legislation Certification quality (support) and control Review laws for health worker protection Implementation and institutionalization of tasks shifting will have to be sanctioned by relevant professional councils, associations and educational bodies. Designing and operating certification schemes Developing standard procedures protocols Development of indicators for HRH performance 2 in HIV/AIDS Jointly train HIV/AIDS workers and community leaders for better community involvement and partnership Leadership training 2 Refer Annex 4 Examples of indicators for monitoring HRH for HIV/AIDS services 4
Costing of HRH related activities Common HRH development activities for costing include but are not limited to: Salaries Contract fees Topping-up and allowances Short course fees Sponsorship of long courses Development / review of a course or curriculum Development / review / printing and distribution of learning materials Development of a policy guideline / strategy Running a seminar or training workshop Staging a meeting Development of a study proposal Procurement of protective devices The general principles of the GFATM R8 costing tool (accessed in http://www.who.int/hiv/pub/toolkits/gf-round8/en/index3.html), are also applicable to the costing of HRH development proposals, taking the following steps: 1. Establish a number of goals 2. Define 3 4 objectives per goal 3. Determine 3 4 service delivery areas (SDA) per objective 4. List several activities per SDA 5. Break down each activity in detailed activity components (DAC) (usually 8 10 per activity) 6. For each activity component, determine the cost component and unit cost 5
Annex 1. Elements of the WHO Priority Interventions for HIV/AIDS that rely heavily on health care providers Priority Interventions: HIV/AIDS prevention, treatment and care in the Health Sector by WHO/HIV Dept. August 2008 ( http://www.who.int/hiv/en/) include the following. All depend on human resources; those that are particularly labour intensive have been bolded. Client initiated HIV testing and counseling Provider initiated HIV testing and counseling Family and partner HIV testing and counseling Infant and children HIV testing and counseling Blood donor HIV testing and counseling Laboratory services for HIV diagnosis Promoting and supporting condom use Detection and management of sexually transmitted infections Safer sex and risk reduction counseling Male circumcision Prevention among people living with HIV Interventions targeting sex workers Interventions targeting MSM and transgender people Specific considerations for HIV prevention in young people Specific considerations for Displaced, mobile and migrant populations Specific considerations for prisoners and people on other closed settings Non-occupational post-exposure prophylaxis Needle and syringe programme (NSPs) Drug dependence treatment Information, education and communication for IDUs Community based care and support Safe injections Safe waste disposal management Occupational health of health care workers Occupational post-exposure prophylaxis (PEP) Blood safety Interventions to prevent illness Co-trimoxazole prophylaxis Preventing fungal infections Vaccinations Nutritional care and support Provision of safe water, sanitation and hygiene Prevention of malaria Antiretroviral therapy for adults, adolescents and children Treatment preparedness and adherence support Patient monitoring Management of opportunistic infections and comorbidities Management of HIV related conditions Management of pneumonia Management of diarrhea Management of malnutrition Management of viral hepatitis Management of malaria Prevention of HIV in infants and young children Family planning, counseling and contraception Antiretroviral medicines to prevent HIV infection in infants Treatment, care and support for women living with HIV, their children and families Infant feeding, counseling and support Prevention and treatment of mental health disorders Counseling Palliative care Tuberculosis prevention, diagnosis and treatment (Co-) treatment of HIV-associated tuberculosis Laboratory services 6
Annex 2 Examples of earlier honored requests The following sorts of requests have been elected for funding in earlier GFATM proposals: Examples from Malawi, Rwanda, Kenya and Ethiopia mentioned in Call for Action: Health System Strengthening through the Global fund Round 9 in 2008 (http://www.healthworekforce.info) Train district health management teams in planning / various management skills (HRH development element 1) Recruitment of additional staff (HRH development element 1) Provision of compensation / salaries (HRH development elements 2, 3) Provide sleeping quarters for health centre staff availing HIV/AIDS related services (HRH development element 2) Development and distribution of job aids (HRH development element 2) Retention of staff (HRH development elements 1) Introduction of clinical mentoring and support supervision (HRH development element 3) Recruiting of community based staff (HRH development element 1) Recruiting of PLWHA (HRH development element 1) Improvement of in-service training (HRH development element 3) Introduce telemedicine services (HRH development element 3) Curriculum development (HRH development element 1, 3) Improve pre-service training (HRH development element 1) Scale up training facilities (HRH development element 1) Develop degree programmes (HRH development element 1) Sponsoring overseas training of nurse tutors (HRH development element 1, 3) Studies on staff motivation (HRH development element 5) Strengthen monitoring and evaluation / operational research (HRH development element 5, 8) Improve health management information systems (HRH development element 5) Recruit and train data clerks (HRH development element 1, 5) 7 March 2009 7