An analysis of GAVI, the Global Fund and
World Bank support for human resources for
health in developing countries
Marko Vujicic,1* Stephanie E Weber,2Irina A Nikolic,3Rifat Atun4and Ranjana Kumar5
1Senior Economist, Human Development Network, The World Bank, Washington DC, USA,2Consultant, The World Bank & Doctoral
Candidate, School of Public Health, University of California, Berkeley, CA, USA,3Health Specialist, Human Development Network,
The World Bank, Washington DC, USA,4Director, Strategy, Performance & Evaluation Cluster, The Global Fund to Fight AIDS, Tuberculosis
and Malaria, Vernier-Geneva, Switzerland and5Program Manager South East Asia, Program Delivery Team, Global Alliance for Vaccines
and Immunisation Secretariat, Geneva, Switzerland
*Corresponding author. Senior Economist, Human Development Network, The World Bank, 1818 H St NW, Washington DC 20433, USA.
Tel:þ1-202-473-6464. Fax: þ1-202-522-3489. E-mail: vujicic74@gmail.com
Accepted 14 December 2011
Shortages, geographic imbalances and poor performance of health workers pose
major challenges for improving health service delivery in developing countries.
In response, multilateral agencies have increasingly recognized the need to
invest in human resources for health (HRH) to assist countries in achieving their
health system goals. In this paper we analyse the HRH-related activities of three
agencies: the Global Alliance for Vaccines and Immunisation (GAVI); the Global
Fund for Aids, Tuberculosis, and Malaria (the Global Fund); and the World
Bank. First, we reviewed the type of HRH-related activities that are eligible for
financing within each agency. Second, we reviewed the HRH-related activities
that each agency is actually financing. Third, we reviewed the literature to
understand the impact that GAVI, Global Fund and World Bank investments in
HRH have had on the health workforce in developing countries. Our analysis
found that by far the most common activity supported across all agencies is
short-term, in-service training. There is relatively little investment in expanding
pre-service training capacity, despite large health worker shortages in developing
countries. We also found that the majority of GAVI and the Global Fund grants
finance health worker remuneration, largely through supplemental allowances,
with little information available on how payment rates are determined, how the
potential negative consequences are mitigated, and how payments are to be
sustained at the end of the grant period. Based on the analysis, we argue there is
an opportunity for improved co-ordination between the three agencies at the
country level in supporting HRH-related activities. Existing initiatives, such as
the International Health Partnership and the Health Systems Funding Platform,
could present viable and timely vehicles for the three agencies to implement this
improved co-ordination.
Keywords Health workforce policy, donor assistance for health, aid harmonizationPublished by Oxford University Press in association with The London School of Hygiene and Tropical Medicine
/C223The Author 2012; all rights reserved.Health Policy and Planning 2012;1–9
doi:10.1093/heapol/czs012
1 Health Policy and Planning Advance Access published February 13, 2012 at Imperial College London Library on February 14, 2012 http://heapol.oxfordjournals.org/ Downloaded from KEY MESSAGES
/C15GAVI, the Global Fund and the World Bank together provide significant financial resources to developing countries to
strengthen the health workforce.
/C15By far the most common activity supported across all agencies is short-term, in-service training. There is relatively little
investment in expanding pre-service training capacity, despite large health worker shortages in developing countries.
/C15Most GAVI and Global Fund grants finance health worker remuneration, with little information available on how
payment rates are determined, how the potential negative consequences are mitigated, and how payments are to be
sustained at the end of the grant period.
/C15There is an opportunity for improved co-ordination between the three agencies at the country level. Existing initiatives,
such as the International Health Partnership and the Joint Health Systems Funding Platform could present viable and
timely vehicles to implement this improved co-ordination.
Introduction
Shortages, geographic imbalances and poor performance
of health workers pose major challenges for improving ser-
vice delivery in developing countries. The World Health
Organization (WHO) estimates that there is a global shortage
of 2.4 million doctors, nurses and midwives based on minimum
staffing levels required to provide essential health services
(WHO 2006 ). Beyond shortages, there are often major
inequities in the geographic distribution of health workers
(WHO 2010 ). Staff productivity and quality of care provided are
also major problems ( Vujicic et al. 2009 ). These health work-
force challenges are a major bottleneck to improved health
systems and health service delivery in developing countries
(WHO 2006 ;TIIFHS 2009a ).
In response, multilateral agencies have increasingly recog-
nized the need to invest in human resources for health (HRH).
The Global Fund for Aids, Tuberculosis, and Malaria
(the Global Fund), since its inception in 2002, has invested in
HRH and has encouraged countries to use its grants for this
purpose through all financing rounds. Through its health
systems strengthening (GAVI HSS) financing stream, the
Global Alliance for Vaccines and Immunisation (GAVI) has
also encouraged countries to include HRH-related activities in
proposals ( GAVI 2007 ;GAVI 2009a ). One of the goals of the
United States President’s Emergency Plan for Aids Relief
(PEPFAR) is to train and retain 140 000 additional health
workers in PEPFAR focus countries by 2014. In the United
Kingdom, the Department for International Development
(DFID) has worked with the government of Malawi to provide
training and base salary support for the country’s medical staff
since 2006 ( DFID 2010 ). Multilateral institutions such as WHO,
the World Bank and the International Labour Organization
have also supported countries to improve their HRH policies
through both lending and policy reform ( WHO 2006 ;World
Bank 2007 ;IEG 2009 ).
Despite increased attention and investment, a systematic
comparative analysis of HRH-related activities funded by
bilateral and multilateral agencies and their impact on the
HRH situation in low- and middle-income countries has not
been carried out. Such an analysis is important at this time.
There is clear commitment among development and financing
agencies operating in the health sector to better co-ordinate
activities and align support behind national health strategies, asis evident in initiatives such as the International Health
Partnership and the Health Systems Funding Platform. These
initiatives aim to better harmonize donor financing commit-
ments, enhance alignment with country systems and improve
the way international agencies, donors and developing coun-
tries work together to develop and implement national health
plans, support country progress toward national health goals,
and accelerate progress toward the Millennium Development
Goals.1
This paper provides a first step in a comparative analysis of
key multilateral agency work in the area of HRH. Specifically,
we examine the HRH-related activities supported through select
financing streams of three multilateral agencies: GAVI, the
Global Fund, and the World Bank. We focus on these agencies
for three reasons. First, these are three major multilateral
agencies that substantially invest in the health sector in low-
and middle-income countries. In 2010, the three agencies
combined accounted for 20% of the total global development
assistance for health and for 53% of all multilateral develop-
ment assistance for health ( IHME 2010 ). Second, these three
agencies, together with WHO, are collaborating to harmonize
health system strengthening actions, including HRH, through
the Health Systems Funding Platform ( TIIFHS 2009b ). The
analysis sheds light on areas where closer agency co-ordination
and alignment is needed. Third, and most important, these
agencies make available data which allows detailed comparative
analysis of country-level investments in health systems
strengthening activities, including for HRH. The specific object-
ives of this paper are to: (i) develop a framework for
categorizing HRH-related activities funded by donor agencies;
(ii) describe which HRH-related activities are eligible for
financing through specific GAVI, Global Fund and World
Bank financing streams; (iii) describe the pattern of financing
for each agency according to type of HRH-related activities; and
(iv) review published peer-reviewed literature to understand
the overall impact of HRH-related donor investments in low-
and middle-income countries on the health workforce.
Methods
Our aim was to capture important differences across the
three agencies in terms of key HRH-management functions
being supported (e.g. training health workers, paying health2 HEALTH POLICY AND PLANNING at Imperial College London Library on February 14, 2012 http://heapol.oxfordjournals.org/ Downloaded from
