PEPFAR

AIDS 2012 - Turning the Tide Together

PEPFAR’s Efforts to Strengthen the Global HIV Healthcare Workforce

Ambassador Eric Goosby, M.D.U.S. Global AIDS Coordinator,

Department of State

Healthcare Worker Shortage & HIV Pandemic

HIV Prevalence (UNAIDS, 2006)

Health Worker : Population Ratio (World Health Organization, 2006)

• 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

The President’s Emergency Plan for AIDS Relief (PEPFAR)

• 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 II (2009-2014)

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

PEPFAR’s HRH Strategy: Vision and Goals

Flow Chart Illustrating Various Points for Policy Intervention in HRH Labour Market

Health Care Education Labor Force Health Care Labor Take-up Rate Participation Force Participation

Rate Rate

High

School

Pool of

Qualified HW

Other

Training

Training

in Health

Non-Health Care

Sector

Health Care

Sector

Un-

employed

Employed

USA, UK

Geographic distribution

Private/Public sector allocation

Absenteeism Skill mix Productivity Quality

MIGRATION

Health Labor Market Dynamics

Adapted from Marko Vujicic, World Bank 2009

PEPFAR’s Human Resources for Health Objectives

1. Strengthen pre-service education institutions2. 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 environments5. Investigate and apply recruitment and retention strategies 6. Improve HRIS and utilization of data for improved management and planning

New HCW

Students

Teachers and Effective Leadership

Infrastructure

Strengthen pre-service education institutions

Objective 1

Source: ITECH

• 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.

Ensure quality of in-service and pre-service training and practicing professionals

Objective 2

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

• 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)

Support the development of new cadres and strengthen the community workforce

Objective 3

• 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

African Health Profession Regulatory Collaborative (ARC)

• Zanzibar & Tanzania: Productivity & Work Climate Study

• Niger, Uganda, & Tanzania: HRH Collaboratives

• Swaziland & Uganda: Wellness Centers for health workers

• Rwanda : national performance -based incentive scheme

Improve health worker motivation and productivity and foster positive workplace environments

143

48

29

198

2631

7

61

0

20

40

60

80

100

120

140

160

180

200

Registration & triage Consultation Dispensing TOTAL

Ave

rag

e tim

e (m

inu

tes)

Clinic service

Average Client Waiting Times in Kabuyanda at Baseline and Follow-up

Average waiting time at baseline Average waiting time at follow-up

* The average waiting time for 'Consultation' at follow-up is a weighted average of 'Consultation with nurse' and 'Consultation with clinician'

Figure 1. Uganda Productivity:Average Client Waiting Times in Kabuyanda Baseline and Follow-up

Objective 4

• 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

Investigate and apply recruitment and retention strategies

Objective 5

• 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

Improve HRIS and utilization of data for improved management and planning

Objective 6

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.

For further information, please visit:www.PEPFAR.gov

www.facebook.com/PEPFAR http://twitter.com/USPEPFAR

Thank You