Climbing a Mountain of Data in Bellagio, Italy: HIV/AIDS Funding and Human Resource for Health

February 12, 2009

Base camp:The HIV/AIDS Monitor is currently in the midst of a research project which explores how the increases in donor funding for HIV/AIDS have had effects on the wider health workforce, particularly in the context of the human resources for health (HRH) crisis. This global crisis is particularly severe in our three study countries of Mozambique, Uganda, and Zambia.

Over the past few months, our research partners in these three countries have collected evidence through cross sectional surveys of facility managers and staff, document reviews, key informant interviews, and from secondary data sources.

Climbing the mountain: Last week we were fortunate to bring our research partners together at the Rockefeller Foundation’s Bellagio Center to share and discuss the evidence they have collected and their plans for analyzing it. On the moody (rainy) shores of Lake Como we discussed how PEPFAR, the Global Fund, and the World Bank Multi-Country AIDS Program are providing large amounts of funding for massive programs to accomplish a particular set of health outcomes, with varying levels of harmonization among them and alignment with nationally established outcomes. We considered our evidence about how people are mobilized to implement these new massive HIV/AIDS programs. Between well regimented meals, served with great efficiency, we attempted to get our heads around the dimension and underlying problems of the HRH crisis in the three countries, and how to best describe the national efforts to develop the health workforce. And with a fair dose of fresh mountain air we contemplated how to use our evidence to better understand the dynamics between national HRH efforts and the massive influx of HIV/AIDS funding, and how policies and plans play out in the experiences of workers and managers. We started the week in Bellagio with a pile of evidence and questions, and left having identified and tested a number of analytical approaches and techniques that will help make sense of a very complex set of issues.

Loose rocks: While it will be some months before our results are ready for publication, it is worth noting an underreported aspect of the HRH crisis that became a recurring theme in our discussion. It is widely recognized that there is a real dearth of knowledge about the health workforce, which has serious and troubling implications for HRH planning, management and (more selfishly) our own research on this topic. Here are a few of the loose rocks we encountered on our climb:

- There is very little reliable data about the health workforce nationally or for donor funded programs. While there are a patchworks of datasets (from health facility inventories, to census data and public records), these are often one-off exercises and/or are very unreliable.
- The private sector (for profit and non-profit) is a giant unknown due to its heterogeneity and lack of documentation. It is particularly difficult to know what the terms of employment are within the private sector.
- There is significant policy fragmentation around the health workforce even within the public sector. Responsibility for planning, resource allocation, training, and management of the health workforce is spread often informally across multiple ministries or agencies. This fragmentation often leads to contradictions and conflicting efforts.

In the next few months the HIV/AIDS Monitor team will collectively ascend the mountain of data, but until we get there let us know your stories about this issue in your country and how these challenges are being addressed.

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1. Jim Campbell Says:
   February 20th, 2009 at 5:50 am

   DFID/PEPFAR – joint programme on HRH.

   I have been working in 2 of the 3 countries covered by your study (Mozambique and Zambia) and had the pleasure to meet Dirce in Maputo. This DFID and PEPFAR work is ongoing under the umbrella of the joint USA/UK HRH initiative launched by former President Bush and Prime Minister Brown.

   Our studies in Mozambique and Zambia identify similar issues to CGD’s onging work. But encouragingly we noted specific efforts coordinated by the Ministry of Health, National AIDS Council, Professional Associations, FBOs, NGOs and Development Partners to address this.

   DFID and PEPFAR are reviewing how their contributions can lend even further support. The concept of ‘Workforce Surveillance’ (across all health sectors), working to the technical strengths of the US agencies who oversee PEPFAR implementation (i.e. CDC’s broader technical advantage in disease surveillance, MIS and GIS) has already been successfully applied in Kenya and is an option for roll-out elsewhere.

   ECSA’s 46th Ministerial Meeting resolved to address ‘workforce surveillance’ through the creation of National Health Workforce Observatories. I would hope your pending report adds further clarity on the actions that the Bank, GFATM and PEPFAR can take to support this through their HIV/AIDS programming.

   Th Mozambique study is available as:
   Jim Campbell & Barbara Stilwell (2008). Mozambique: Taking Forward Action on Human Resources for Health (HRH) with DFID/OGAC and Other Partners. Available on World Wide Web: http://www.hrhresourcecenter.org/node/2307

   The Zambia study will be available shortly.

2. Michael Clemens Says:
   March 4th, 2009 at 6:31 pm

   It’s true that data on health professionals in Africa can be abysmal. True story: When I contacted the Nigerian Ministry of Health in 2005 to ask how many nurses there were in Nigeria, I was told on official letterhead that they had not been counted since 1992.

   Some readers of this post might be interested in a dataset that I collected on the number of African-born doctors and nurses residing *abroad*, in 9 different destination countries, at the time of the last census round. The full dataset is here:

   http://www.cgdev.org/content/publications/detail/12908/

   These numbers have a very small margin of error because the censuses in the destinations are exhaustive and reliable.

3. Johanna Hanefeld Says:
   March 12th, 2009 at 8:58 am

   I have been working on the role of World Bank MAP, Global Fund and PEPFAR, in ART roll-out in both Zambia and South Africa, and have drawn on your publications in the past. I have also had the the good fortune to discuss the Zambia research a number of times with Caesar, but thought I share with the wider team.

   We have just published a paper on the impact of GHIs on human resources in Zambia, which is very qualitative, so slightly different to your approach, but maybe of interest nonetheless. Please see the link below.

   http://www.human-resources-health.com/content/pdf/1478-4491-7-8.pdf

   I very much look forward to your report on HRH.

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