Human resources for health (HRH) are an essential component not only of health systems, but of PEPFAR's efforts to transition to sustainability and increased country ownership. Partner governments cannot manage, operate, oversee, or finance programs if they do not have a trained workforce to carry out these tasks. Shortages are especially notable in the health care workforce sector. Six partner countries with significant PEPFAR investments do not meet the World Health Organization's "Health For All" standard of one medical doctor per 5,000 population; in Mozambique, 600 doctors serve a population of 18 million people.¹¹

PEPFAR supports partner countries in developing a healthy, competent, and motivated workforce. Strategically placed USG investments expand and improve the functioning of the health care workforce. An emphasis on holistic pre-service education, which prepares workers to address both HIV and broader health care needs, should replace the dominant emphasis on in-service HIV-specific trainings. By involving secondary education students in allied health professions training, countries will strengthen the capacity of pre-service education institutions and cultivate new generations of health care workers.

PEPFAR is training a mix of doctors, nurses, and paraprofessional workers (those with six months or more of training). In addition, PEPFAR is working to train community health workers to provide basic health services. PEPFAR is also facilitating increased country-level civil service capacity to carry out all functions of a health system. Supported HRH activities include the following:

Helping countries develop and utilize HRH strategies

Most countries have a national HRH plan for the health sector, but not all countries use these plans for workforce planning. PEPFAR is working to assist countries to develop and implement short- and long-term strategies to build the health workforce and address issues of distribution, density, and performance. Such strategies support cross-cutting and mutually reinforcing interventions, including those involving policy, financing, and information systems. Strategies should address the need for new professional school curricula and capacity. Through such efforts, PEPFAR supports schools in increasing the number of competent clinicians and nurses equipped to take an integrated, problem-oriented approach to care.

Expanding efforts to create innovative training and retention schemes across the six building blocks of health systems

In order to support a successful program at the country level, a health system needs epidemiologists, laboratorians, technicians, health economists, facility administrators, and a whole host of functional employees. PEPFAR has already engaged in some innovative programming to attract health care workers, including task-shifting, reemployment of retirees, and short-term hiring. In order to effectively manage and oversee programming, PEPFAR will work with partner countries to attract and retain a well-trained, technically-oriented cadre of civil servants throughout government health programs. Potential incentives include salary support, creation of safe working conditions, opportunities for expanded training, and academic and research opportunities.

Expanding integration in conjunction with the Global Health Initiative

The doctors, nurses, and other health professionals treating PLWHA are not simply treating HIV - they are also preventing, diagnosing and treating the range of conditions experienced by people living with HIV. These clinicians must have a background in HIV, primary care, pediatrics, reproductive health, and a range of other specialty services. And these clinical services cannot take place without managers, hospital administrators, outreach workers, and others who are critical components of health systems. PEPFAR is expanding efforts to engage in joint training efforts with other USG health programs at the country level. These programs, where appropriate, should be packaged with additional element-specific curricula in order to provide a strong primary care background to health care providers. In addition, PEPFAR is working to ensure that training opportunities are not limited to clinical professionals, but expanded to other professionals who support health systems.

Engaging in multilateral action around larger policy issues

The problem of brain drain involves multiple countries, and must be addressed through multilateral mechanisms. PEPFAR continues to work with the WHO, World Bank, International Monetary Fund (IMF) and others to support discussions about various policy mechanisms that can improve worker retention at the country level.

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