PEPFAR’s Efforts to Strengthen the
Global HIV Healthcare Workforce
Ambassador Eric Goosby, M.D.
U.S. Global AIDS Coordinator,
Department of State
AIDS 2012 - Turning the Tide Together
Healthcare Worker Shortage & HIV Pandemic
Health Worker : Population Ratio
(World Health Organization, 2006)
HIV Prevalence
(UNAIDS, 2006)
The President’s Emergency Plan
for AIDS Relief (PEPFAR)
• PEPFAR I: 2003-2008
– Priority: Scaling-up HIV/AIDS treatment, care and prevention
– Challenge: Not enough health care workers HIV training
– Focus on in-service training to teach HIV skills to existing health
workers, task shifting/task sharing HIV services, and some
integration of HIV content into pre-service degree programs
• Task shifting
– “Game changer” in scaling-up HIV treatment, care, and
prevention
– Support for WHO Task-shifting Guidelines
PEPFAR II (2009-2014)
• Priority: Health Systems Strengthening
– Country ownership and sustainability of HIV programs
– Congressional mandate to train and support retention of 140,000 new
health care workers, with an emphasis on doctors, nurses, and
midwives
– The Human Resources for Health 2009 inter-agency technical working
group strategy involves: “Strengthening regulatory bodies and
professional associations”, including nursing organizations
• World AIDS Day 2012
– Recognizing critical role of nurses and midwives to meet new targets:
• 6 million on ART
• 1.5 million pregnant women on ART
• 4.7 million voluntary medical male circumcision
PEPFAR’s HRH Strategy: Vision and Goals
Vision: Appropriate number and distribution of qualified health
workers who meet the HIV and other health needs of the
population
Goals:
• Increase the Density of Health Workforce
– Number
– Cadres
• Balance Distribution of Health Workforce
– Geographic location
– Sector
– Gender
• Improve Performance of Health Workforce
– Quality
– Efficiency
Health Labor Market Dynamics
Flow Chart Illustrating Various Points for Policy Intervention in HRH Labour Market
Health Care Education
Labor Force
Take-up Rate
Participation
Rate
Health Care Labor
Force Participation
Rate

Health
Care
Sector
High
School
Training
in
Health
Pool of
Qualified
HW
Employed
Unemployed
Other
Training
MIGRATION
USA, UK
Adapted from Marko Vujicic, World Bank 2009
NonHealth
Care
Sector





Geographic
distribution
Private/Public
sector
allocation
Absenteeism
Skill mix
Productivity
Quality
PEPFAR’s Human Resources for
Health Objectives
1. Strengthen pre-service education institutions
2. Ensure quality of in-service and pre-service training and
practicing professionals
3. Support the development of new cadres and strengthen the
community workforce
4. Improve health worker motivation and productivity and
foster positive workplace environments
5. Investigate and apply recruitment and retention
strategies
6. Improve HRIS and utilization of data for improved
management and planning
Objective 1
Strengthen pre-service
education institutions
New HCW
Students
Teachers and
Effective Leadership
Infrastructure
Source: ITECH
Objective 2
Ensure quality of inservice and pre-service
training and practicing
professionals
• MEPI/NEPI
• East Africa: multi-country learning
collaborative to strengthen
regulatory bodies and professional
associations
• Uganda & Tanzania: Evaluating
country in-service HIV/AIDS
training programs
• Global: twinning partnerships in
ten countries in Africa and Russia.
Health Workforce Initiatives
• PEPFAR’s medical and nursing pre-service training
initiatives:
– Competitive awards to African institutions (MEPI)
– Grants to specific countries to identify and support priority
interventions to nursing institutions (NEPI)
– Transformative Guidelines (WHO) and related activities
• Objectives of initiative –
–
–
–
–
–
Workforce capacity - numbers and quality
Education and training more relevant to country needs
Innovative education models
Research capacity (MEPI)
Evidence based policies and technical materials
Costs of effective strategies
Medical and Nursing Education Partnership Initiative
• PEPFAR initiative under the direction of the Office of the U.S.
Global AIDS Coordinator
• PEPFAR Implementing agencies, U.S. Department of Health and
Human Services,
– Health Resources and Services Administration (HRSA),
HIV/AIDS Bureau
– National Institutes of Health (NIH), Fogarty Center
– Coordinating Centers
• George Washington University, Wash DC
• Columbia University, NY
• Other partners (non-USG):
– WHO – Transformative Guidelines – Policy and Technical
– CHAI and USAID/Capacity Plus
Directory of Awards Medical Education Partnership Initiative
(MEPI) and Nurse Education Partnership Initiative (NEPI)
•
•
•
•
•
•
•
•
•
•
•
•
•
Botswana
Ethiopia
Ghana
Kenya
Lesotho (NEPI only)
Malawi (MEPI/NEPI)
Mozambique
Nigeria
South Africa
Tanzania
Uganda
Zimbabwe
Zambia (MEPI/NEPI)
PEPFAR/WHO Collaborative:
Transformative Medical Nursing and
Midwifery Education Guidelines
• Purpose: To support the new political and resource
commitments by providing sound policy and technical
guidance
• Apply to a wide range of providers and promotes the
efficient use of providers through task shifting
• Promotes innovation:
– interdisciplinary teams
– Service networks
• Supports the decentralization of education and
training with consideration to rural programs
• Builds on and promotes the use of existing WHO
policies
Objective 3
Support the development of new
cadres and strengthen the
community workforce
• WHO: Task-shifting guidelines
• Mozambique & South Africa:
Development of new cadres
• GHWA: Community Health Workers
study
• Global: Community Health Worker
Program Assessment and Improvement
Matrix (CHW AIM)
African Health Profession Regulatory
Collaborative (ARC)
• Four-year initiative to strengthen nursing and midwifery leadership and
regulation in 17 sub-Saharan African countries
• Objectives
–
–
–
–
Ensure high quality practice standards
Ensure updated regulatory frameworks
Strengthen nursing and midwifery councils
Cultivate African nursing leadership
• Approach
–
–
–
–
–
Regional conferences
South-to-south collaboration
Regulation improvement grants
Targeted technical assistance
Evaluation science
Objective 4
Improve health worker
motivation and
productivity and foster
positive workplace
environments
Figure 1. Uganda Productivity:
Average Client Waiting Times in Kabuyanda Baseline and Follow-up
Average Client Waiting Times in Kabuyanda at Baseline and Follow-up
Average waiting time at baseline
Average waiting time at follow-up
198
200
180
160
Average time (minutes)
• Zanzibar & Tanzania: Productivity
& Work Climate Study
• Niger, Uganda, & Tanzania: HRH
Collaboratives
• Swaziland & Uganda: Wellness
Centers for health workers
• Rwanda : national performance based incentive scheme
143
140
120
100
80
61
60
40
48
26
31
20
29
7
0
Registration & triage
Consultation
Dispensing
TOTAL
Clinic service
* The average waiting time for 'Consultation' at follow-up is a weighted average of 'Consultation with nurse' and 'Consultation with clinician'
Objective 5
Investigate and apply
recruitment and retention
strategies
• WHO: Retention recommendations
for increasing access to health
workers in remote and rural areas
• Mozambique & Swaziland:
Retention & Quality of Services
study
• Tanzania: Recruiting health students
from rural areas
• Global: Developing
recommendations for measuring
retention in PEPFAR countries
Objective 6
Improve HRIS and
utilization of data for
improved management and
planning
• Global: Implementing iHRIS (open
source software) in 14 countries
• Kenya: Public Health HR Information
System and Workshop being
expanded for use in other countries
• Uganda: Work with MOH & MOF on
resource planning
• Global: HRM Rapid Assessment Tool &
Curricula development
From: “Zeroing In: AIDS Donors and Africa’s Health
Workforce” – Oomman, Wendt, Droggitis. Center for
Global Development. August 2010
Expanding the Evidence Base:
Research & Innovation
• Tools
–
–
–
–
HRH Action Framework (http://www.capacityproject.org/framework/)
Rapid Discrete Choice Experiment (DCE) Tool
Employee Engagement Tool
TrainSMART
• Implementation Science
–
–
–
–
Impact of task-shifting on ART delivery (multi-country)
Effectiveness and attrition of providers in PEPFAR-funded health centers (Ethiopia)
Study on Success Factors for Management Capacity Building Sustainability
Impact of Task Shifting for ART Delivery on Patient and Process Outcomes in
Uganda
– Nurse-initiated and managed HIV Treatment in Policy, Education, and Practice in 17
African countries
– Measuring the Impact of On-Site Mentorship on Nurse and Clinical Officer’s HIV
and TB Care and Competencies
– Descriptive Study of Nursing and Midwifery Practice and Education Regulation in
East, Central, and Southern Africa
Considerations Going Forward
• An appropriate balance between ‘quantity and
quality’.
• Multi-sectoral approaches, particularly
between health and education sectors
• Long term, sustainable changes in areas of
recruitment, education/training, and
retention.
• The use of evidence-based information with
demonstrated effectiveness in LMIC.
• Affordable in LMIC.
Thank You
For further information, please visit:
www.PEPFAR.gov
www.facebook.com/PEPFAR
http://twitter.com/USPEPFAR