Working in Health: Financing and Managing the Public Sector Health Workforce

1. Working in Health:Financing and Managing the Public Sector Health Workforce Appendix E – Review of GFATM Round 6 and GAVI HSS Round 1 Policies and Practices for Funding Health Worker Remuneration Marko Vujicic, KelechiOhiri, Susan Sparkes with Sherry Maddan The World Bank, Washington, DC

2. Outline • GFATM and GAVI policies on funding health worker remuneration • Country practices • Analysis of all GFATM round 6 proposals • Analysis of all GAVI HSS Round 1 approved grants • Key consideration in using GFATM and GAVI resources to pay health workers

3. Policies on Funding Remuneration • GFATM and GAVI have quite flexible policies toward funding health worker remuneration. However, a key condition is sustainability. • GFATM • Guidelines (Round 7) state that HRH activities will be funded if a strong link between the proposed activities and the three target diseases can be demonstrated • Sustainability of the activities at the end of the proposal period needs to be outlined. • Proposed must be linked to a clear national human resource development plan, and must link HRH activities to target diseases. • GAVI • Guidelines state “health workforce mobilization, distribution and motivation targeted at those engaged in immunization, and other health services at the district level and below” is a major priority area for funding. • GAVI HSS support can be used for one-off expenditures that increase system capacity such as pay for performance, contracting with nongovernmental organizations (NGOs), as well as for recurrent expenditures such as fuel, and per diems for outreach. • Sustainability of these expenditures when GAVI HSS funds are no longer available must be demonstrated. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

4. Country Practices • Average share of grant used for paying health workers: • 12% for GAVI HSS • 16% for GFATM • But large variations across countries • Ranges from 0 to 28% (Kenya) within GAVI HSS • Ranges from 0 to 46%(Indonesia, malaria) within GFATM Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

5. Country Practices • Method of remunerating health workers varies • GFATM • Most common form of remuneration is salary payments. • Only 1-in-5 grant pay allowances, per diems or performance-based incentives to health workers • GAVI • Allowances and performance-based incentives are used much more extensively. • For example, 100% of payment to staff in the Burundi grant are for performance-based incentives • Salary payments are much less common Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

6. Country Practices • A significant portion of payments to staff members are for frontline health workers. • GFATM • 30% of GFATM grants have some share of their budget devoted to paying frontline health workers • 36% of GFATM grants finance some administrative and managerial staff member remuneration • Remuneration to frontline health workers mostly in the form of salaries • GAVI • Five of six GAVI HSS grants supported payments to frontline health workers. • Remuneration to frontline health workers mostly in the form of allowances, often performance-based. • Analysis suggests that • GAVI HSS grants focus more on supplementing income and improving the performance of the current • health workforce • GFATM grants focus more on creating newly funded positions, thereby expanding the health workforce. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

7. Country Practices

8. Key Considerations • There are key consideration in using donor resources to pay health workers • Some emerging evidence indicates this can create wage distortions in some countries but evidence is inconclusive • In Ethiopia, jobs in HIV-related services became more attractive after GFATM resources became available • In Benin, facilities supported through GFATM grants followed the government pay scale and had just as much trouble attracting staff as government facilities. Very little labor movement out of government facilities occurred • A driver for a bilateral agency in Addis Ababa was paid more than a professor in the medical faculty, and a government public health specialist could earn four to five times more by joining an international nongovernmental organization • Sustainability issues are not always dealt with adequately • In 56% of cases when GFATM resources are used to pay health workers there is no explicit agreement on whether the government will absorb the cost at the end of the grant. • In 9% of cases are short-term contracts matching the term of the grant used.

9. Key Considerations • When donor funds flow through the government budget the contingent liability depends on the type of contract • With permanent contracts, when the donor funding expires, the government will assume a financial obligation for remuneration payments • With short-term contracts, the government has more flexibility in adjusting staffing levels in response to donor aid flows • Donor aid for health is volatile, unpredictable, and short term (for example, GFATM grants are for a period of at most five years). • In countries examined, short-term contracts are not extensively used in the public sector • Current donor aid architecture and the contracting arrangements within the public sector pose a challenge in not creating contingent liabilities for the government