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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 , Kelechi Ohiri , Susan Sparkes with Sherry Maddan

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working in health financing and managing the public sector health workforce

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

outline
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
policies on funding remuneration
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.

country practices
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.

country practices5
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.

country practices6
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.

key considerations
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.
key considerations9
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