**(NOT FOR DISTRIBUTION)**

**EVALUATION OF USAID**

**HUMAN CAPACITY DEVELOPMENT**

**IN HEALTH**

**Carol D. Brancich**

**Andrew Kantner**

**August 2003**

**Submitted by**

**LTG Associates, Inc.**

**Global Health and Development Strategies**

**a division of Social & Scientific Systems, Inc.**

**Submitted to:**

**The United States Agency for International Development**

**Under USAID Assignment No. 2003-134**

**ACRONYMS**

CA Cooperating Agency

CC Country Coordinator

CDC Centers for Disease Control

CIDA Canadian International Development Agency

DIFD Department for International Development, United Kingdom

GH Bureau for Global Health

HCD Human capacity development

HHS (Department of) Health and Human Services

HIDN (Office of) Health, Infectious Disease, Nutrition

HIV/AIDS Human immunodeficiency virus/acquired deficiency syndrome

HPN (Office of) Health, Population, Nutrition

HRM Human resource management

IMF International Monetary Fund

JSI John Snow, Inc.

MAQ Maximizing Access for Quality

NIH National Institutes of Health

OHA (Office of) HIV/AIDS

PI Performance improvement

PRH (Office of) Population and Reproductive Health

QA Quality assurance

RCS (Office of) Regional and Country Support

Reps Representatives

TA Technical Advisors

USAID United States Agency for International Development

WHO World Health Organization

WB World Bank

**ACKNOWLEDGMENTS**

The Team would like to express its gratitude to the Global Health Bureau
staff, to the staff of POPTECH, and to survey respondents and those
individuals who participated in the interviews. The evaluation benefited
greatly from the time and effort contributed by these individuals.

## EXECUTIVE SUMMARY

The purpose of this evaluation is to provide an overview of Human
Capacity Development HCD activities across the four main offices of the
United States Agency for International Development's (USAID's ) Bureau
for Global Health (GH) and recommend options for addressing future HCD
needs in health service provision. This evaluation report was undertaken
for GH's Task Force on Human Capacity Development.

USAID has a long and relatively successful track record in various
aspects of HCD for health service providers throughout the developing
world. Unfortunately, previous USAID investments in HCD have been
eroding (and in much of Sub-Saharan Africa quickly disappearing) in
recent years. Recognition of this looming crisis has been slow to take
hold within the donor community and will require aggressive "catch-up"
action if health delivery systems are not to deteriorate further.

Much of the evidence compiled for this evaluation was derived from
in-person and telephone interviews. The Team interviewed GH senior
management staff, Country Coordinators (CCs), GH Cognizant Technical
Officers (CTOs), USAID Population, Health, and Nutrition staffs residing
in overseas missions, and CA Representatives. A short on-line survey of
HCD was sent to the same individuals who participated in the qualitative
interview sessions. The survey collected information on current HCD
activities, future HCD needs, and actionable short and long-term HCD
priorities that might be considered for incorporation by USAID in future
activities.

Results from the survey indicate that there is broad agreement that
USAID should give greater emphasis to HCD in the future and that current
projects could be doing more to strengthen HCD for service providers.
Most respondents agreed that the per-capita availability of health
service providers had declined over the past decade. This view was
especially marked among USAID Mission respondents in sub-Saharan Africa.

Most survey respondents were in agreement that future HCD needs in
service provision will be concentrated in HIV/AIDS, maternal and child
health, infectious disease and other reproductive health services (e.g.,
adolescent programs and post-abortion care). In the survey responses,
family planning was not ranked highly as a future HCD priority area. In
order to meet future demand for health care, it was noted that greater
resources will need to be allocated for the training of nurse/midwives,
paramedics (including various types of auxiliary workers), and community
workers (including community-based fieldworkers and outreach workers).
Lower priority was given to doctors, traditional nurse-midwives, and
traditional healers.

The most important HCD needs typically identified by survey respondents
were in-service training, staff deployment, employee incentives,
conditions of service, and pre-service training. Instituting better
time/attendance reporting and the training of human resource specialists
were ranked as the lowest priority areas.

When survey respondents were asked whether USAID could be effective in
changing specific policies and practices in HCD (given host country
political, regulatory and legal environments), there was considerable
skepticism concerning the Agency's ability to significantly influence or
assume responsibility for many HCD areas. For example, most respondents
indicated that issues surrounding staff recruitment, staff retention,
time/attendance reporting, civil service reform, and conditions of
service were likely beyond USAID's ability to do much about. Respondents
were more optimistic that USAID could play an important role in HCD
activities that have been traditionally supported (e.g., pre and
in-service training as well as the certification/accreditation of
service providers), technical fields such as workload planning, and the
training of human resource managers.

Findings, conclusions and recommendation based on interview information
were organized according to four HCD classifications for action
identified by the HCD Task Force - legal, policy and financial; human
resource management (HRM); leadership; and, partnerships. Provision of
service issues spans all four of these elements. Major findings under
these headings are summarized below:

####### 

####### Legal, Policy, Financial

###### Bureau Structure

The vertical organizational and appropriations funding structures of GH
are seen as presenting problems for focused, strategically directed
cross-bureau HCD emphasis and/or initiatives. Lack of permeability
between Office walls was cited by CA, Mission and Bureau respondents
alike as being an obstacle in cross-office HCD areas. Because of the
vertical nature of GH's structure, a variety of CAs and bilateral
organizations under different programs currently work independently on
HCD issues. They often do not collaborate. This current fragmented
approach is viewed as costly in expended resources and time.

> [Recommendation 1]{.underline}: Advocacy by senior management levels
> of GH is required for undertaking HCD initiatives.
>
> [Recommendation 2]{.underline}: Establish the need for consensus on
> joint programming and funding for HCD initiatives in GH.
>
> **Salary Structures**

In many country programs, limitations in host country salary structures
and their companion civil service regulations were cited as almost
insurmountable barriers to HCD. A number of respondents reported salary
imbalances as root causes for current service provider supply and
retention problems. Antiquated personnel administration systems are
reported to be in place in many countries, often deeply entrenched in
the governmental culture. Performance appraisals are reported as largely
nonexistent and certainly not linked to actual performance, neither in
terms of quality nor in quantity.

[Recommendation 3]{.underline}: Salary issues should be explored in
selected countries to identify potential mechanisms for improving levels
and/or imbalances in service provider remuneration, including partnering
with other donors in this endeavor.

##### Essential Commodities

Problems in shortages of supplies, equipment, drugs and facilities
shortcomings were reported as compounding the difficulties of service
providers in quality of care provision. Lack of essential supplies was
seen as greatly reducing providers' abilities to successfully fulfill
standards of practice and also as a contributing factor to heightened
worker frustration. Insufficient local financial resources were named as
playing a large role in the shortages.

[Recommendation 4]{.underline}: As procurement requirements in OHA
continue to be delineated, GH should expand existing logistic management
systems rather than creating new ones. Cross-bureau coordination must be
strengthened using previous lessons learned (e.g., established
purchasing, warehousing, and distribution systems).

***Human Resource Management (HRM)***

**Country Strategic Plans**

A number of Mission strategic plans include a Strategic Objective (SO),
i.e. Egypt; Intermediate Objective (IR), e.g. Cambodia, Kenya; or
sub-IR, e.g. South Africa, that would support HCD activities. Other
Missions indicated that even though no specific IR for HCD exists in
their strategic plans there would be no specific prohibition to
conducting such activities. Emphasis on HCD and its system components
have to date not been a priority in GH programming and funding. Findings
indicate that all Missions contacted are facing HCD needs.

> [Recommendation 5]{.underline}: In collaboration with USAID field
> missions, consider undertaking HCD needs assessments in selected
> countries with success potential that will generate information on
> priority HCD needs in health.
>
> [Recommendation 6]{.underline}: Based upon the HCD needs identified
> through these assessments, propose mechanisms for incorporating HCD
> activities in USAID's country strategic plans.

**Integrated Broad Scale HCD Programming**

This evaluation noted that numerous and scattered HCD activities are
being conducted throughout most CA projects and in bilateral agreements.
However, broad scale integrated HCD efforts were not reported.
Disjointed CA and bilateral HCD efforts are achieving output objectives,
and although contributing to HCD practice improvement to varying
degrees, they are not reported to be achieving long-term sustainability
in HCD. Additionally, very little if any operations research or
evaluation to assess HCD approaches has been conducted.

> [Recommendation 7]{.underline}: Integrated HCD should adopt a systems
> development approach in its programming.
>
> [Recommendation 8]{.underline}: Integrated HCD should include
> evaluation and operations research to determine the effectiveness of
> different HCD approaches and the potential for replicating successful
> models.

**Realignment of Service Provider Categories/Cadres**

Due to human resource crises in numerous countries, certain provider
cadres are either being stretched far beyond polyvalence and/or being
raided to staff crisis service areas. Others are leaving their
employment. New service demands are being made of already overburdened
staffs that are not necessarily the most appropriate cadre for
performing the task. Respondents recognized the need for allocation of
required skill sets to non-professional worker cadres.

> [Recommendation 9]{.underline}: Expand and realign the categories of
> service providers in the health workforce (e.g., community health
> workers, paramedics, auxiliary health workers, and pharmacists, and
> home care workers).
>
> [Recommendation 10]{.underline}: Redesign required skill sets for
> capacity development and supervision systems required to accommodate
> service provider realignment.

####  Training Practices

Over utilization of in-service training as an exclusive means of
bolstering HCD gaps was reported quite frequently. Respondents support
the notion that in-service needs will always exist especially in
selected technical areas. However, they also acknowledge that invariably
a policy of using in-service training in lieu of pre-service education
is in practice.

> [Recommendation 11]{.underline}: In-service training should be
> carefully targeted to address performance gaps in newly identified
> tasks being added to job requirements or to personnel as new
> technologies and knowledge requirements emerge.

**Pre-Service Education and Long-Term Training**

In many of the countries canvassed, current professional leadership
capacity is seen as weakening and not being readily replaced.
Professional schools are under-funded, lack needed technology and
updated training approaches and are unable to meet current health care
delivery demands. Clinical expertise in very complex HIV/AIDS
prevention, treatment and care modalities is reported as lacking, as
well as expert management skills to carefully balance other essential
health services, e.g. child survival, immunization,
population/reproductive, maternal-neonatal.

Loss of GH technical support for pre-service institutions, curriculum
revision and long-term training is evident in the diminishing numbers of
public health professionals and upper level managers. The concept of
'twinning' with US-based university programs for long-term training is
also considered at a diminished level, thereby lessening the supply of
cadres such as trained public health professionals.

> [Recommendation 12]{.underline}: Recommit to pre-service education and
> long-term training with emphasis on supporting regional and
> south-to-south educational and training institutions and US twinning
> mechanisms.
>
> [Recommendation 13]{.underline}: In order to effectively address HCD
> policy reforms and restructuring, USAID needs to be working not only
> with Ministries of Health, but also possibly with Ministries of
> Finance (for education funding), Ministries of Education (for nursing
> and medical education), and Ministries of Labor (for remuneration
> levels, incentive structures, and conditions of work).

# Leadership

**Finding: HCD Category/Cadre**

A leadership layer of expert, well-practiced HCD leaders and managers
does not appear to exist within any of the countries contacted, neither
at central nor decentralized levels. No respondents reported broad scale
training or mentoring of HCD managers and no one reported HCD in
pre-service curriculum.

> [Recommendation 14]{.underline}: Pre-service education and in-service
> training in HCD management should be initiated to develop a critical
> mass of managers dealing with prevailing HCD issues.

#### Cooperating Agencies, PHN Field and GH Staff

HCD leadership qualities and technical expertise within CAs were
described by field and GH respondents as ranging from non-existent to
limited. CA activities in contacted countries were often seen to be
repetitive in nature. The approaches were interpreted as being "off the
shelf" (e.g., in-service training and supervision models) and not
addressing the complexity of the country's HCD problems. Sharing HCD
experience and active collaboration among organizations is not currently
being done. Bringing many of the GH technical expertise areas (e.g.
quality assurance, performance improvement, curriculum design, training
of trainers, management and supervision) together to collectively
resolve service provider performance dilemmas would begin to ensure
strengthened HCD systems supportive to various program achievements.

> [Recommendation 15]{.underline}: Increase general awareness of HCD
> issues within GH and across CA organizations and establish
> consultative mechanisms for sharing project experiences and
> identifying best practices including those from Maximizing Access to
> Quality (MAQ), performance improvement (PI), and quality assurance
> (QA).
>
> [Recommendation 16]{.underline}: Clarity of language in CA annual work
> plans is highly desirable regarding the range and type of CA efforts
> in HCD. This would bolster awareness and confidence regarding HCD
> capacities within CA organizations and throughout the CA community.

# Partnerships

**Donor Coordination in HCD**

Few respondents reported actual partnering with other donors in the HCD
sphere (e.g., the World Bank, EU, DIFD or CIDA). The potential for donor
partnering is reported to be within the HCD components of personnel
administration (salaries paid) and integration of HR and health system
objectives (civil service reform).

US organizations were also identified as either having presence or the
potential for in-country partnering, e.g. Centers for Disease Control
(CDC), Health and Human Services (HHS), National Institutes of Health
(NIH), and US foundations - Gates, Hewlett, Packard. Several respondents
were concerned by the lack of consistent GH senior-level participation
in discussions with these organizations to assure that USAID is seen and
acknowledged for its technical assistance capacity.

[Recommendation 17]{.underline}: Host country representatives and
organizations should be considered full partners in developing and
implementing any HCD initiatives.

> [Recommendation 18]{.underline}: Substantive liaison between USAID GH
> and potential partners such as the WB, WHO, and EU would greatly
> increase the potential for success in HCD.
>
> [Recommendation 19]{.underline}: Participation at senior management
> levels with other US organizations (e.g., CDC, NIH, and HHS) is
> required for administrative and programmatic partnering in health HCD
> efforts.

Based upon the findings and recommendations from this assessment,
concrete next steps were identified for consideration by the GH Task
Force on HCD. These are as follows:

1\. Develop an HCD Strategy that articulates HCD needs and identifies
the scope and depth of priority HCD initiatives GH may be prepared to
support (within each office and jointly). This strategy should be guided
by USAID's programmatic experience, current technical capabilities, and
careful assessments of the potential for success. This is an overarching
recommendation for the evaluation.

2\. Implement an Integrated HCD Country Initiative. This activity would
address priority HCD needs in a selected number of countries where the
potential for programmatic action appears promising. The objective of
this initiative would be to field test various HCD initiatives in
diverse country environments in order to identify successful models for
action, best practices in HCD, and interventions that appear to have
good potential for replicability.

3\. Review the status of GH's internal and contractual mechanisms for
supporting Long-Term Training in the United States.

4\. Evaluate the potential of Professional Exchange Programs and
Collaboratives in Health as effective HCD strategies.

5\. Better position USAID to assume a more prominent Global Leadership
Role in HCD for health.

> I. INTRODUCTION

*Purpose of the Evaluation*

In recent years there has been a growing recognition of the need to
better address human capacity development (HCD) needs in health service
delivery in developing countries. This concern has been driven both by
the ever-growing client base for health care and by the HIV/AIDS crisis
that has decimated the ranks of service providers in countries that have
been hit hard by the epidemic. There is currently considerable concern
that the international donor community is not making the long-term
investments in human resources and health system reform needed to ensure
the provision of accessible and high quality care.

The purpose of this evaluation is to provide an overview of HCD
activities across the four main offices of United States Agency for
International Development (USAID) Bureau for Global Health (GH) and
recommend options for addressing future HCD needs in health service
provision. These GH offices are the Office of Population and
Reproductive Health (PRH), the Office of HIV/AIDS (OHA), the Division of
Health, Infectious Disease, and Nutrition (HIDN), and the Office of
Regional and Country Support (RCS).

This evaluation report was undertaken for GH's Task Force on Human
Capacity Development. This Task Force includes representatives from all
four offices within GH. As stated in the original Scope of Work, the
purpose of this evaluation is to "present a series of options for the
HCD Task Force related to USAID's manageable interest regarding the
type, extent, and level of involvement in HCD in the health sector as it
relates to service delivery". Specific activities for this evaluation
are as follows:

1.  Finalize questions pertaining to HCD that will be asked of Missions,
    Cooperating Agencies (CAs), and GH staff in response to current HCD
    activities and facilitate an exercise that reviews and revises
    (where needed) the goals and objectives of the HCD Task Force.

2.  Conduct a survey of global health and bilateral projects to
    determine what is being done in HCD

3.  Make a series of recommendations (in the forms of options) to the
    Task Force as to how GH should support HCD in the future.

*Background*

USAID has a long and relatively successful track record in the training
of health service providers throughout the developing world. In recent
decades these efforts have shifted from longer-term pre-service training
(focusing on the production of new doctors) to in-service training of
nurse/midwives and various types of auxiliary and community-based
workers. The training of individual service providers has also tended to
supplant USAID's earlier commitment to investing for the long-term in
educational and training organizations in developing countries
(institution building).

Unfortunately, previous USAID investments in HCD have been eroding (and
in much of Sub-Saharan Africa quickly disappearing) in recent years.
Recognition of this looming crisis has been slow to take hold within the
donor community and will require aggressive "catch-up" action if health
delivery systems are not to deteriorate further.

In many Sub-Saharan African countries, a growing shortage of new service
providers (and skill sets) relative to projected health care needs
(disease burdens) is occurring. Low salaries, poor working conditions,
and the effect of economic decline combined with donor-driven structural
readjustments of the public sector have all contributed to the rapidly
growing human resources crisis within the health sectors of many
sub-Saharan countries. Dwindling investments in regional and national
medical and nursing schools (as donors shy away from pre-service
training involvements) is also making it more difficult for many
developing countries to produce the number and type of health workers
they need.

Professional health sector cadres are also shrinking in many African
countries owing to the morbidity/mortality impact of the HIV/AIDS
crisis. Current evidence suggests that around 20 percent of the African
health workforce will eventually be lost to the HIV/AIDS epidemic
(Tawfik and Kinoti, 2001:3). In addition, HCD needs are being
exacerbated by the emigration of health workers from poorer countries to
settings with higher salaries and improved career prospects, and the
early retirement of health workers owing to low salaries, poor working
conditions, and the growing danger of treating sick patients with new
infectious diseases.

In other regions of the developing world, HCD issues can take on a very
different complexion. In countries such as Egypt and South Africa, HCD
problems are often viewed more in terms of staff deployment, retention,
and achieving an appropriate mix of skills among new service providers
rather than a problem of undersupply per se (although both Egypt and
South Africa presently have severe nursing shortages).

While HCD needs have reached crisis proportions in many developing
countries, especially those significantly impacted by the HIV/AIDS
epidemic, worries about how to best train, deploy, and retain service
providers have bedeviled international health experts for decades. Much
donor-driven HCD activity has focused on the in-service training of
individual practitioners with respect to specific program areas (e.g.,
in family planning and reproductive health, maternal and child health,
and the diagnosis, treatment, and prevention of specific infectious
diseases such as malaria, polio, and TB). While these efforts have no
doubt made useful contributions, they are increasingly viewed as
inadequate in terms of improving the overall functionality and
performance of health systems and enhancing the delivery of health care
in resource poor settings.

Owing to the growing awareness that much HCD technical assistance has
failed to greatly enhance individual and institutional capacities or
produce sustainable results, there is a growing recognition that HCD
initiatives should go well beyond the never-ending need to provide
training to individual service providers. Instead, it is increasingly
recognized that HCD issues need to be articulated in relation to the
health environments (disease burdens) of specific countries or regions
and be engaged within the functional context of indigenous health
systems. In other words, HCD interventions need to be highly sensitive
to in-country managerial and resource realities, programmatic need, and
political sensitivities in order to be successful.

While upgrading the knowledge and competencies of individual service
providers will continue to be a central feature of any HCD strategy,
other HCD needs come into sharper relief when considering how HCD inputs
contribute to the outcomes generated by health systems. One respondent
participating in this evaluation succinctly summed up matters as
follows:

> Donor projects tend to focus on the production of health workers,
> supervision training, and the quality of work done by providers
> (mainly in the public sector). The real issues in HCD are distribution
> of health manpower within a country, motivation of workers to perform
> primarily related to salary and benefits, and drug and supply
> logistics so that workers have the materials they need to actually
> perform the work the systems ask of them. We generally don't consider
> these areas as HCD issues, but they are (POPTECH Respondent, 2003).

For the purposes of this evaluation, HCD is defined as the process of
developing the abilities, skills, and motivation of service providers to
deliver high quality health services. Meeting HCD needs also entails
strengthening human resource management in order to ensure the effective
supply, deployment, and retention of health manpower within a health
delivery system. Perhaps the term human resources management (HRM) would
better describe the complex of components considered in this report.
However, for the sake of clarity, the term HCD will be used in this
report.

The GH Task Force has identified five major HCD components in
considering current and future HCD needs in health service
provision[^1]. Similar typologies have been adopted by other
international and bilateral donor organizations (e.g., WHO, the World
Bank, DFID, and CIDA) in their efforts to respond to HCD needs in
health. These components are described in Table 1.

As is obviously apparent, the five HCD components listed in Table 1
constitute a broad, some might say unmanageable programmatic agenda. Not
only are HCD agendas far ranging, but they often involve sensitive
issues pertaining to program ownership, domestic legal and regulatory
practices, cultural bureaucratic environments, and ultimately national
sovereignty. However, if these crucial health input "issues" are not
adequately dealt with in the future, it is unlikely that health systems
will be capable of generating the hoped-for outputs (results) everyone
would like to see. Picazo et al., (2003) succinctly summarize the
dilemma of HCD in terms of the immediate health challenges facing
Africa.

> A key factor in the neglect of health workers' (HCD) issues is the
> view held by governments and donors that HR (human resources) is too
> big, too complex, and too intractable to be solved by one donor or by
> the government alone depending on its meager resources. A second
> factor is the tradition that donor projects can only provide resources
> for capital costs or for foreign exchange requirements (e.g., drug
> imports, international technical advisory services, or staff training
> abroad), but not for recurrent costs, and certainly not for salary
> support or enhancement. A third factor is the continuing fragmentation
> of African health systems largely balkanized by donor projects, each
> having its own overlapping set of HR sub-systems, incentive
> structures, training programs, and disease priorities. Clearly the HR
> problem is the elephant in the room that both donors and African
> governments have ignored and that is now throwing its weight around
> (Picazo et al., 2003:36).

Another challenge facing HCD is that short-term project cycle
perspectives don't fit well with the long-term investment strategies
that will be needed to make lasting headway. As one respondent in this
evaluation noted, HCD requires a marathon rather than sprint mentality
when developing interventions and programming resources. This
longer-term perspective will entail adjustments in USAID's current
predilection for project assistance tied to the achievement of
short-term results.

*Methodology*

A two-person team experienced in human capacity development, manpower
planning, and service provision in developing countries undertook this
evaluation

+-----------------------------------------------------------------------+
| Table 1: Major Components of Human Resources in Health                |
+-----------------------------------------------------------------------+
| 1.  Staff Supply: What people recruited for health programs and where |
|     do they work?                                                     |
|                                                                       |
|     a.  Deployment: Defining and filling positions.                   |
|                                                                       |
|     b.  Job Description: Specifying the role of different categories  |
|         of workers, including the mix of different skill sets.        |
|                                                                       |
|     c.  Recruitment: Identifying candidates for staff positions       |
|         relating to health system needs.                              |
|                                                                       |
|     d.  Career Development: Developing promotion criteria and         |
|         policies for employees and providing career opportunities     |
|         based on performance.                                         |
+-----------------------------------------------------------------------+
| 2.  Performance Management: Managers have some objective means for    |
|     evaluating the performance of their staff and the authority to    |
|     act on evaluations.                                               |
|                                                                       |
|     a.  Performance Appraisal Systems: Evaluating the performance of  |
|         health staff using clear criteria and records.                |
|                                                                       |
|     b.  Time/Attendance Reporting: Maintaining routine system records |
|         pertaining to who is working, where they are working, and for |
|         how long.                                                     |
|                                                                       |
|     c.  Incentives: Rewarding or sanctioning employees based on       |
|         performance.                                                  |
+-----------------------------------------------------------------------+
| 3.  Personnel Administration and Employee Relations: There are formal |
|     rules and procedures governing the management of personnel        |
|     issues, other than individual performance.                        |
|                                                                       |
|     a.  Conditions of Service: Instituting job requirements, fringe   |
|         benefits, and rights of employees.                            |
|                                                                       |
|     b.  Terms of Employment: Establishing salary scales, requirements |
|         for full versus part time employment, flexibility in hours    |
|         worked, contracting procedures and regulations.               |
|                                                                       |
|     c.  Labor Relations: Union representation, collective bargaining, |
|         role of professional organizations.                           |
|                                                                       |
|     d.  Staff Promotion: Explicit criteria and policies are in place. |
+-----------------------------------------------------------------------+
| 4.  Education and Training: Do professional and technical educational |
|     institutions and in-service training programs support an overall  |
|     assessment of system needs?                                       |
|                                                                       |
|     a.  Coordination of Pre-Service Education: Adopting pre-service   |
|         educational planning,                                         |
|                                                                       |
| > coordinating health education needs and standards across            |
| > ministries, and developing professional managed HR units.           |
|                                                                       |
| b.  In-Service Training: Usually the largest area of donor support,   |
|     but to what degree does this fit into an overall plan?            |
|     Instituting competency testing and the systematic maintenance of  |
|     training records and undertaking research to improve              |
|     cost-effectiveness.                                               |
|                                                                       |
| c.  Certification: Attaining formal recognition based on demonstrated |
|     skills or knowledge; applies to private sector providers.         |
|                                                                       |
| d.  Accreditation: Periodically evaluating training programs based on |
|     well-defined standards.                                           |
|                                                                       |
| e.  Licensing: Adhering to formal legal requirements for practicing a |
|     profession, which may t involve competency testing or periodic    |
|     re-testing, or continuing education requirements.                 |
+-----------------------------------------------------------------------+
| 5.  Integration of Human Resources and Health System Objectives:      |
|     Changes at the policy level may involve broader health sector     |
|     reform, or go beyond the health sector.                           |
|                                                                       |
|     a.  Civil Service Reform: Instituting changes in civil service    |
|         regulations to increase performance; may require changes in   |
|         law or high-level political decisions.                        |
|                                                                       |
|     b.  Staffing Needs Assessment/Workload Planning: Evaluating the   |
|         actual amount of work different categories of staff are       |
|         carrying out, followed by corresponding plans to get the most |
|         out of available workers.                                     |
|                                                                       |
|     c.  Formal, Transparent Management of Human Resources: More       |
|         effectively managing human resources on the basis of formal   |
|         procedures that reflect the needs of a health care system as  |
|         found in a human resources plan or evaluation                 |
|                                                                       |
|     d.  Training and Other Support for Human Resource Specialists and |
|         Units: Upgrading the professional qualifications and          |
|         experience of HR practitioners (e.g., in general personnel    |
|         administration) and deal with challenges to HR management     |
|         posed by decentralization.                                    |
+-----------------------------------------------------------------------+
| Heiby (2003).                                                         |
+-----------------------------------------------------------------------+

for the GH Task Force on HCD. Much of the evidence compiled by the team
was derived from in-person interviews and phone calls. The team
interviewed GH Country Coordinators (CCs), GH Cognizant Technical
Officers (CTOs), USAID Population, Health, and Nutrition staffs residing
in overseas missions, and CA Representatives. A complete list of persons
contacted as part of this evaluation is shown in Appendix VI.

A short online questionnaire (administered through surveymonkey.com)
consisting of 25 questions was also deployed as part of this evaluation.
The questionnaire was sent to the same individuals that were contacted
for phone interviews. The survey collected information on current HCD
activities, future HCD needs, and actionable short and long-term HCD
priorities that might be considered for incorporation by USAID in future
activities.

As part of this evaluation, a brief review of HCD activities being
undertaken by other multilateral and bilateral donor organizations was
undertaken. This information was compiled through phone interviews and
by visiting web sites of relevant organizations (e.g., the World Bank
and World Health Organization). The team also reviewed USAID project
documents pertaining to HCD, including research studies, progress
reports, management reviews, and training evaluations.

This assessment is not a detailed formal evaluation of all HCD
activities in health currently being implemented by USAID (either
through bilateral projects or centrally-funded organizations). It does
provide a general overview of current HCD activities and policies within
GH and proposes options for enhancing HCD strategies relevant to
achieving future strategic objectives in health.

> II\. FINDINGS FROM THE EVALUATION SURVEY ON

HUMAN CAPACITY DEVELOPMENT

A short survey of human capacity activities and future priorities was
undertaken as part of this evaluation. The survey was administered to GH
CCs, CTOs, Population, Health, and Nutrition Officers in USAID field
missions, and representatives from USAID's CA community. The countries
and CAs selected for inclusion in this survey are shown below. While the
number of respondents for the survey was not large (and the level of
response among GH CCs and CTOs somewhat disappointing), it is still
possible to a degree to identify essential characteristics of current
HCD activities and future need. Results from the survey are presented in
Appendices II-V.

The range of potential HCD issues is extensive and varies considerably
across regions and individual country settings. However, there is also
broad agreement that USAID should give greater emphasis to HCD in the
future and that current projects could be doing more to strengthen HCD
for service providers.

  ----------------------------------- -----------------------------------
  **Table 2: Countries and            
  Cooperating Agencies Contacted for  
  the Survey on Human Capacity        
  Development**                       

  **Countries Contacted**             **Cooperating Agencies Contacted**

  Bangladesh                          PHR+/Abt Associates

  Cambodia                            Basics II

  Egypt                               Catalyst

  Indonesia                           EngenderHealth

  Kenya                               JHPIEGO/TRH

  Malawi                              JSI/Deliver

  Nigeria                             MSH/M&L

  Senegal                             Pathfinder

  South Africa                        PRIME II

  Uganda                              URC/QAWD

  Ukraine                             

  Zambia                              
  ----------------------------------- -----------------------------------

Respondents identified several HCD problems (or imbalances) that are
seriously affecting the accessibility and quality of health services in
many developing countries. For example, USAID Missions noted that too
few new service providers are being trained and that too many existing
providers are concentrated in urban areas (see Appendix V, Table 2). CA
Representatives (Reps) also stated that the ratio of doctors to nurses
is too high in many settings and that highly trained doctors with
specialized skills tend to be over-represented in relation to general
practitioners. Somewhat surprisingly, very few USAID Missions (only
Zambia) reported that the emigration of health workers is a significant
problem affecting the deployment and retention of health workers in
their countries.

+----------------------------------+-----------------------------------+
| **Table 3: Priority HCD Problem  |                                   |
| Areas as Reported by Survey      |                                   |
| Respondents**                    |                                   |
+----------------------------------+-----------------------------------+
| **GH Country Coordinators and    | **GH CTOs and Cooperating         |
| USAID Mission Staff**            | Agency**                          |
|                                  |                                   |
|                                  | **Representatives**               |
+----------------------------------+-----------------------------------+
| Ratio of Urban to Rural          | Ratio of Urban to Rural Providers |
| Providers Too High               | Too High                          |
+----------------------------------+-----------------------------------+
| Ratio of Doctors to Nurses Too   | Ratio of Doctors to Nurses Too    |
| High                             | High                              |
+----------------------------------+-----------------------------------+
| Few New Service Providers        | Few New Service Providers         |
| Entering Service                 | Entering Service                  |
+----------------------------------+-----------------------------------+

Most respondents agreed that the per-capita availability of health
service providers had declined over the past decade. This view was
especially marked among USAID Mission respondents in sub-Saharan Africa
(e.g., Senegal, Malawi, Uganda, and Zambia), where availability was
often described as having "greatly deteriorated". In general, rural
service availability appears to have declined more rapidly than in urban
areas, which suggests that future HCD efforts will need to give greater
weight to improving service delivery in more remote areas. Respondents
also report that the per-capita availability of family planning service
provision has declined relative to HIV/AIDS, maternal and child health,
infectious disease, and other reproductive health services during this
same time frame.

There is general agreement that the impact of HIV/AIDS has greatly
increased the need to train more service providers and address HCD
issues. This view is especially pronounced among USAID Missions in
sub-Saharan Africa. The growing appreciation for HCD issues in health
service delivery may also be reflected by the large percentage of
developing countries that have recently requested assistance in
addressing HCD needs. For example, 89 percent of all USAID Missions and
88 percent of CA Reps say that they have received requests for technical
assistance in HCD. Respondents also report that other donors are
becoming more active in HCD work. However, donor coordination on HCD
issues is generally weak, and appears to be highly country-specific.

In spite of this growing concern, many of the countries surveyed do not
have specific HCD strategies in place that allocate resources for health
service providers. Among countries with HCD strategies, priority appears
to be given to HIV/AIDS service provision, with infectious disease and
nutrition receiving the least attention (especially as reported by CA
Reps). HCD components (listed in Table 1) that typify these strategies
include personnel administration and the education/training of service
providers. The supply system for health, performance management, and the
integration of human resource competencies in heath system planning tend
to receive less attention.

Respondents provide a somewhat inconsistent depiction of the extent to
which HCD issues have been incorporated in strategies for addressing
future health service delivery needs. Eighty percent of GH/CCs say that
USAID has adopted comprehensive HCD strategies at the country level,
while only 50% of USAID Missions report having such strategies in place.
However, all respondents report that USAID is actively engaged in the
education and training of service providers, primarily of the in-service
rather than pre-service variety. Other HCD components are relatively
neglected at the present time.

GH Country Coordinators, USAID Missions, and CA Reps agree that
USAID-funded training activities for health service providers have not
been systematically evaluated. Only GH CTOs seem to be of the view that
evaluation is not a current deficiency. Curiously, in situations where
this training has been evaluated, GH and USAID Mission staffers are more
skeptical about the effectiveness of these efforts. For example, only 25
percent of USAID Missions rated in-country training activities as
"highly effective", whereas 100% of CA Reps thought that USAID-funded
training events warranted this rating.

Current training activities funded by USAID appear to be focusing
primarily on doctors and nurse/midwives. Respondents report that low
priority is now being given to training traditional nurse/midwives,
paramedics, community workers, and traditional healers. All but one of
the five CTOs responding to this survey said that nurse/midwives are
currently being accorded low priority in USAID's training activities, a
depiction very much at odds with replies from Country Coordinators,
USAID Missions, and CA Reps.

All respondents were in agreement that future HCD needs in service
provision will be concentrated in HIV/AIDS, maternal and child health,
infectious disease and other reproductive health services (e.g.,
adolescent programs and post-abortion care). Family planning was not
ranked highly as a future HCD priority area.

In order to meet future demand for health care, it was generally agreed
that greater resources need to be allocated for the training of
nurse/midwives, paramedics (including various types of auxiliary
workers), and community workers (including community-based fieldworkers
and outreach workers). Lower priority was given to doctors, traditional
nurse-midwives (a cadre that has received considerable attention from
USAID in countries such as Bangladesh and Indonesia in the past), and
traditional healers.

+----------------------------------+-----------------------------------+
| **Table 4: Program Areas in      |                                   |
| which Future Demands on Service  |                                   |
| Provider HCD will be Most        |                                   |
| Critical**                       |                                   |
+----------------------------------+-----------------------------------+
| **GH Country Coordinators and    | **GH CTOs and Cooperating         |
| USAID Mission Staff**            | Agency**                          |
|                                  |                                   |
|                                  | **Representatives**               |
+----------------------------------+-----------------------------------+
| HIV/AIDS                         | HIV/AIDS                          |
+----------------------------------+-----------------------------------+
| Maternal and Child Health        | Infectious Disease                |
+----------------------------------+-----------------------------------+
| Other Reproductive Health        | Maternal and Child Health         |
| Services                         |                                   |
+----------------------------------+-----------------------------------+

+----------------------------------+-----------------------------------+
| **Table 5: Type of Health Worker |                                   |
| that should receive Priority     |                                   |
| Attention in Meeting Future HCD  |                                   |
| Needs**                          |                                   |
+----------------------------------+-----------------------------------+
| **GH Country Coordinators and    | **GH CTOs and Cooperating         |
| USAID Mission Staff**            | Agency**                          |
|                                  |                                   |
|                                  | **Representatives**               |
+----------------------------------+-----------------------------------+
| Nurse/Midwives                   | Nurse/Midwives                    |
+----------------------------------+-----------------------------------+
| Community Workers                | Community Workers                 |
+----------------------------------+-----------------------------------+
| Paramedics                       | Paramedics                        |
+----------------------------------+-----------------------------------+

As noted in Table 1, HCD includes a broad array of issues and potential
interventions. Respondents were asked to rank these HCD elements in
terms of their level of importance in individual countries or across the
project activities of Cooperating Agencies participating in this
evaluation. While there was some variation in findings when comparing
the four respondent categories employed by this survey, informants
typically identified in-service training, staff deployment, employee
incentives, conditions of service, and pre-service training as the most
important needs in HCD. Instituting better time/attendance reporting and
the training of human resource specialists were ranked as the lowest
priority HCD issues. According to information supplied by USAID
missions, these results generally applied across the countries surveyed
for this evaluation (see Table 4 in Appendix V).

+----------------------------------+-----------------------------------+
| ## Table                         |                                   |
|  6: Current Priority HCD Needs a |                                   |
| s Reported by Survey Respondents |                                   |
+----------------------------------+-----------------------------------+
| **GH Country Coordinators and    | **GH CTOs and Cooperating         |
| USAID Mission Staff**            | Agency**                          |
|                                  |                                   |
|                                  | **Representatives**               |
+----------------------------------+-----------------------------------+
| In-Service Training              | Staff Deployment                  |
+----------------------------------+-----------------------------------+
| Employee Incentives              | Employee Incentives               |
+----------------------------------+-----------------------------------+
| Conditions of Service            | Pre-Service Training              |
+----------------------------------+-----------------------------------+

Unfortunately, the HCD priorities identified in this survey do not
always correlate well with USAID\'s perceived programmatic and technical
competencies in HCD. When respondents were asked whether USAID could be
effective in changing specific policies and practices in HCD (given host
country political, regulatory and legal environments), there was
considerable skepticism concerning the Agency's ability to significantly
influence and assume responsibility for many HCD areas.

For example, most respondents indicated that issues surrounding staff
recruitment, staff retention, time/attendance reporting, civil service
reform, and conditions of service were likely beyond USAID's ability to
do much about. Respondents were more optimistic that USAID could play an
important role in HCD activities that have been traditionally supported
(e.g., pre and in-service training as well as the
certification/accreditation of service providers), technical fields such
as workload planning, and the training of human resource managers.

+-----------------------------------+-----------------------------------+
| **Table 7a: HCD Components that   |                                   |
| USAID Resources and Technical     |                                   |
| Assistance could Likely Impact**  |                                   |
+-----------------------------------+-----------------------------------+
| **GH Country Coordinators and     | **GH CTOs and Cooperating         |
| USAID Mission Staff**             | Agency**                          |
|                                   |                                   |
|                                   | **Representatives**               |
+-----------------------------------+-----------------------------------+
| Pre-Service Training              | In-Service Training               |
+-----------------------------------+-----------------------------------+
| Certification/Accreditation       | Pre-Service Training              |
+-----------------------------------+-----------------------------------+
| In-Service Training               | Certification/Accreditation       |
+-----------------------------------+-----------------------------------+
| **Table 7b: HCD Components in     |                                   |
| which USAID Resources and         |                                   |
| Technical Assistance would Likely |                                   |
| Have Little or No Impact**        |                                   |
+-----------------------------------+-----------------------------------+
| **GH Country Coordinators and     | **GH CTOs and Cooperating         |
| USAID Mission Staff**             | Agency**                          |
|                                   |                                   |
|                                   | **Representatives**               |
+-----------------------------------+-----------------------------------+
| Staff Retention                   | Staff Recruitment                 |
+-----------------------------------+-----------------------------------+
| Time/Attendance Reporting         | Time/Attendance Reporting         |
+-----------------------------------+-----------------------------------+
| Civil Service Reform              | Conditions of Service             |
+-----------------------------------+-----------------------------------+

**III. INTERVIEW FINDINGS, CONCLUSIONS AND RECOMMENDATIONS**

In-person and telephone interviews were also conducted as part of this
evaluation using the five HCD Component areas specified in Table 1 as
the basis for discussions. As noted in the Methodology section, the same
respondents that were sent the survey questionnaire were contacted for
interviews.

The findings, conclusions and recommendation based on interview
information have been organized according to four HCD classifications
for action identified by the HCD Task Force - legal, policy and
financial; human resource management (HRM); leadership; and,
partnerships. Provision of service issues spans all four of these
elements.

####### Legal, Policy, Financial

###### Finding: Bureau Structure

The vertical organizational and appropriations funding structures of GH
are seen as presenting problems for focused, strategically directed
cross-bureau HCD emphasis and/or initiatives. Lack of permeability
between Office walls was cited by CA, Mission and Bureau respondents
alike as being an obstacle in cross-office HCD areas such as, but not
limited to, standardization in delivery system supervision, personnel
deployment, frontline worker task and skill requirements (job
descriptions), and training management, logistical and supply management
systems. One respondent described the need as "lacking a corporate
consensus regarding HCD."

HCD leadership within GH was not apparent to those interviewed. That a
Bureau wide Task Force has been commissioned to assess HCD needs and
activities, was welcome new information for respondents. Of special
importance to Mission respondents was the possibility that monies could
be mixed to effect broader changes in HCD in meeting overlapping service
demands and the needs of an integrated (polyvalent) workforce.
Co-mingling of funds across Bureau offices in a balanced way was
described as being desirable. Several of the Mission officers reported
recent shifts in program priorities as causing imbalances in previously
emphasized service areas; e.g. ID, child survival, family planning.

Because of the vertical nature of GH's structure, a variety of CAs and
bilateral organizations under different programs currently work
independently on HCD issues in a number of countries. They occasionally
collaborate yet often do not. This current fragmented approach is viewed
as costly in expended resources and time. Although a variety of outputs
are reported being produced, scattered approaches under this vertical
construct appear to be producing very few sustainable, stable changes in
the five HCD Components.

Field officers, by and large, understand the need for HCD although vary
in their assessments as to which of the five HCD Components apply in
their situation. Several respondents noted that the creation of a GH
task force charged with exploring HCD issues was in itself a sign for
GH's leadership that these issues are

priorities and that cross-office programming is needed.

###### Conclusion

Collaborative, joint venture HCD programming and funding are needed
within GH. Systemic issues confront program and project implementation
across the Bureau's offices. In health delivery systems dependent upon
polyvalent workers and/or service providers performing multiple tasks,
HCD is at the heart of quality assurance and service delivery
efficiency. HCD constraints of staff supply, performance management,
personnel administration, education and training and integration of HCD
and health system objectives are critical programming issues across all
GH offices.

Cross-office strategic planning is fundamental to HCD technical
expertise being well coordinated and strategically directed. Minimizing
redundancy in efforts, maximizing resource investments, and programming
strategically directed interventions would produce a greater degree of
stability and sustainability in health service infrastructure components
than is currently being achieved. Vertical programming for HCD is not
dealing with the broad systemic issues satisfactorily. The question of
HCD as a means (input) leading to strategic outcomes and not an outcome
in itself seemed to have value for several respondents.

##### Recommendations

> [Recommendation]{.underline} [1]{.underline}: Advocacy by senior
> management levels of GH is required for undertaking HCD initiatives.
>
> [Recommendation]{.underline} [2]{.underline}: Establish the need for
> consensus on joint programming and funding for HCD initiatives in GH.
>
> **Finding: Salary Structures**

In many country programs, limitations in host country salary structures
and their companion civil service regulations were cited as almost
insurmountable barriers to HCD. A number of respondents reported salary
imbalances as root causes for current service provider supply and
retention problems. Antiquated personnel administration systems are
reported to be in place in many countries, often deeply entrenched in
the governmental culture.

Additionally, in lieu of salary supplements or salary structure change,
training stipends for in-service participants were frequently cited as
being used as an incentive factor by USAID. Although effective to a
point, training participant stipends were described as ultimately
unsatisfactory especially when competing with other donors' provision of
long term salary supplements that result in frequent employee transfers
to donor salary supplemented projects.

Performance appraisals are reported as largely nonexistent and certainly
not linked to actual performance, neither in terms of quality nor in
quantity. Subsequently, performance appraisal linked to performance
remuneration, incentives, or salary adjustments are not readily
encountered.

> **Conclusion**

Delays in or avoidance of civil service reforms continues the problems
of salary inequities, employee retention, deployment imbalance and poor
job performance. It is acknowledged that HCD policy restructuring is not
always within the exclusive control of the Ministry of Health (MOH).
Other ministries are frequently involved like those of Finance and
Labor. Therefore, whole-scale MOH transformation is undoubtedly not
possible in most countries; rather, incremental changes could be
effected in selected countries.

In a few select countries, where the potential for broader
infrastructure interventions is highest, partnering with other donors to
address root cause factors would be of most benefit. GH need not assume
full responsibility, but rather it could provide the technical expertise
for which USAID is best positioned and partner with those donors able to
provide funding, e.g. Department for International Development-United
Kingdom (DIFD), World Bank (WB).

##### Recommendation 

[Recommendation 3]{.underline}: Salary issues should be explored in
selected countries to identify potential mechanisms for improving levels
and/or imbalances in service provider remuneration, including partnering
with other donors in this endeavor.

##### 

##### Finding: Essential Commodities

Problems in shortages of supplies, equipment, drugs and facilities
shortcomings were reported as compounding the difficulties of service
providers in quality of care provision. Lack of essential supplies was
seen as greatly reducing providers' abilities to successfully fulfill
standards of practice and also as a contributing factor to heightened
worker frustration. Insufficient local financial resources were named as
playing a large role in the shortages. Inefficient logistic management
procedures also play a role. Frontline service delivery is dependent on
availability of proper and sufficient commodities to perform well.
Burdening frontline workers with logistical management tasks was
reported as needing restructuring, especially where specific management
criteria are essential to safety in pharmaceutical logistics, e.g. cold
chain for immunizations, shelf-life for ARVs.

**Conclusion**

Developing and maintaining well functioning supply and equipment systems
is seen as being critical to the quality performance factor for
providers. Within GH, large numbers of lessons learned in this area
already exist, especially in the Offices of HIDN and PRH. As the
requirements in OHA continue to be delineated, expanding existing
logistic management systems could be more quickly and efficiently
achieved than creating new ones.

###  Recommendation

[Recommendation 4]{.underline}: As procurement requirements in OHA
continue to be delineated, GH should expand existing logistic management
systems rather than creating new ones. Cross-bureau coordination must be
strengthened using previous lessons learned (e.g., established
purchasing, warehousing, and distribution systems).

***Human Resource Management (HRM)***

**Finding: Country Strategic Plans**

A number of Mission strategic plans include a Strategic Objective (SO),
i.e. Egypt; Intermediate Objective (IR), e.g. Cambodia, Kenya; or
sub-IR, e.g. South Africa, that would support HCD activities. Other
Missions indicated that even though no specific IR for HCD exists in
their strategic plans there would be no specific prohibition to
conducting such activities, e.g. Uganda. One country, Senegal, did
report severe office staff shortages as a barrier to currently adding
HCD to their workload. Several Missions contacted have the potential for
HCD system interventions within the five HCD Components. Two Missions,
Cambodia and South Africa, show promise and interest in programming for
a number of the five HCD Components, and in Cambodia in perhaps in all
five components. Other Missions show promise in programming in a few
selected components - Kenya, Malawi, Uganda, and Ukraine. Egypt has
already embarked on a major pre-service curricula reform and expects to
complete it within two years. It is understood that Egypt has other
potential HCD programming areas.

**Conclusion**

Emphasis on HCD and its system components have to date not been a
priority in GH programming and funding. The findings indicate that all
Missions contacted are facing HCD needs. It seems logical that HCD
planning should be a priority in those country strategic plans and in
their GH programming. A 'corporate HCD consensus' spanning GH and field
offices vis-à-vis health programs is in order. Careful (1)
identification of the root cause issues of HCD problems, (2) selection
of feasible interventions and (3) developing HCD activities to address
priority problems is warranted. Those country field programs noted above
require further exploration/assessment.

##### Recommendations

> [Recommendation 5]{.underline}: In collaboration with USAID field
> missions, consider undertaking HCD needs assessments in selected
> countries with success potential that will generate information on
> priority HCD needs in health.
>
> [Recommendation 6]{.underline}: Based upon the HCD needs identified
> through these assessments, propose mechanisms for incorporating HCD
> activities in USAID's country strategic plans.

**Finding: Integrated HCD Programming**

In response to whether activities were in progress or recently completed
in any of the five HCD Components, numerous and scattered HCD activities
were reported as being conducted throughout most CA projects and in
bilateral agreements. These activities included large numbers of
in-service training activities; some activities in supervision
strengthening (Malawi, Zambia); one bilateral funded pre-service
curriculum reform initiative (Egypt); and a few CA activities in
decentralized HCD strengthening (Zambia). Of special note are those CAs
whose objectives already include HCD components. An illustrative list
includes INTRAH/PRIME II, URC/QAWD, JHPIEGO/TRH, Abt/PHR +, and
PI/Catalyst. Additionally, other CAs without HCD objectives also report
involvement in some aspect of the five Components, e.g. BASICS II,
EngenderHealth. Yet, broad scale integrated HCD efforts were not
reported.

In addition to numerous small-scale interventions taking place some
Missions and CCs reported two or more CAs working independently in
countries. Linkages and cohesiveness between interventions are not
occurring. At least two countries reported that current CAs are not
systems-oriented and so continue to function within comfort-level zones
of skills training-both technical and managerial. Only two CAs were
described as oriented to systems development, yet the impression is that
other CAs could and should redirect their efforts.

Disjointed CA and bilateral HCD efforts are achieving output objectives,
and although contributing to HCD practice improvement to varying
degrees, they are not reported to be achieving long-term sustainability
in HCD. Delivery infrastructures are reported as crumbling and are not
able to sustain new service demands being placed upon many of them.
Additionally, very little if any operations research or evaluation to
assess HCD approaches has been conducted.

**Conclusion**

Over the years, USAID in-service and pre-service investments have been
well received and recognized as being beneficial, yet training/education
alone does not guarantee quality of service practice nor better health
outcomes. A range of events in many countries has led to deterioration
in health service infrastructures and consequently, erosion of USAID
prior investments. Close attention is needed to assure that CA
interventions are responding to strategic HCD needs.

Approaches in the five HCD Components, added to continuing the time
honored activities of the component for in-service and pre-service
education, are required to attend to weakened ineffective HCD systems
within fragile health delivery infrastructures. Review of the input from
interview and survey respondents indicate that without concentrated,
well-directed inputs into HCD systems, host country health delivery
infrastructures will further erode and even further lessen the
achievement potential of GH programmatic outputs/outcomes. And, without
operations research and evaluation, HCD approaches and practices may or
may not produce lasting and replicable HCD advances.

##### Recommendations

> [Recommendation 7]{.underline}: Integrated HCD should adopt a systems
> development approach in its programming.
>
> [Recommendation 8]{.underline}: Integrated HCD should include
> evaluation and operations research to determine the effectiveness of
> different HCD approaches and the potential for replicating successful
> models.

**Finding: Realignment of Service Provider Categories/Cadres**

Due to human resource crises in numerous countries, certain provider
cadres are either being stretched far beyond polyvalence and/or being
raided to staff crisis service areas. Others are leaving their
employment. Factors cited for departure by health workers include
emigration, retirement, stress, economic hardship due to salary
inequities and/or non-payment, HIV/AIDS morbidity/mortality and fear of
acquiring infection, and health system reorganization with position
redundancy or redeployment. Service areas are reported to be unattended,
staffed with unskilled providers, or with overburdened and disheartened
providers. A disproportionate distribution of personnel, e.g. urban to
rural, continues to be a problem in many country programs and compounds
the issue of staff deployment.

New service demands are being made of already overburdened staff that
are not necessarily the most appropriate cadre for performing the task.
Respondents recognized the need for allocation of required skill sets to
non-professional worker cadres. However it must be acknowledged that
this call for realignment of frontline provider tasks requires skill
capacity development and supervision and management adjustments to
accommodate the realignment up and down the service provider line.

**Conclusion**

Traditional professional cadres, e.g. physicians, nurses,
nurse-midwives, can no longer be considered as the frontline workers
through which the bulk of services can be provided. Numbers are
dwindling, replacement numbers are not keeping up with attrition, new
skills and tasks are being required, cost effectiveness in workforce
expenditures is paramount, and management capacity is vitally needed.
Reducing barriers to professional practice would allow for job task
realignment.

Expanding or realigning the service provider workforce pool presents new
challenges in HCD. Inclusion of such personnel categories as community
workers, pharmacists and outreach and home care workers, to name a few,
is required. Additionally, performance improvement principles would need
to be applied and quality of care standards established.

##### Recommendations

> [Recommendation 9]{.underline}: Expand and realign the categories of
> service providers in the health workforce (e.g., community health
> workers, paramedics, auxiliary health workers, and pharmacists, and
> home care workers).
>
> [Recommendation 10]{.underline}: Redesign required skill sets for
> capacity development and supervision systems required to accommodate
> service provider realignment.

#### Finding: Training Practices

Over utilization of in-service training as an exclusive means of
bolstering HCD gaps was reported quite frequently. Respondents support
the notion that in-service needs will always exist especially in
selected technical areas. However, they also acknowledge that invariably
a policy of using in-service training in lieu of pre-service education
is in practice. In-service training has been substituted to fill the
gaps in pre-service curricula and education that over years continue to
exist and have not yet been revised to meet emerging care practice and
competency needs.

##### 

##### Conclusion 

Over reliance on in-service training as the producer of such yields as
quality of care, improved supervision and others may reflect
misinterpretation of the root causes for gaps in these areas. It may
also reflect selecting the most familiar, more easily programmed
intervention with assurance of output numbers. In-service training when
appropriately used can successfully assist with adding new knowledge and
skills to existing personnel cadres. However, its application should be
carefully targeted to address performance gaps in newly identified tasks
being added to job requirements or in the updating of personnel as new
technology/knowledge requirements emerge. The use of in-service training
as a singular intervention tool to deal with systemic service delivery
issues has not necessarily been proven to be effective.

> **Recommendation**
>
> [R]{.underline}[ecommendation 11]{.underline}: In-service training
> should be carefully targeted to address performance gaps in newly
> identified tasks being added to job requirements or to personnel as
> new technologies and knowledge requirements emerge.

**Finding: Pre-Service Education and Long-Term Training**

Respondents frequently cited regret regarding the erosion that has
occurred over recent years due to the policy shift in GH financial
support reduction for the pre-service education and US-based long-term
investments made by USAID in previous years. As leadership ranks
dwindle, the need to attend to the supply side of HCD cannot be left
unaddressed.

In many of the countries canvassed, current professional leadership
capacity is seen as weakening and not being readily replaced.
Professional schools are under-funded, lack needed technology and
updated training approaches and are unable to meet current health care
delivery demands. Clinical expertise in very complex HIV/AIDS
prevention, treatment and care modalities is reported as lacking, as
well as expert management skills to carefully balance other essential
health services, e.g. child survival, immunization,
population/reproductive, maternal-neonatal.

Loss of GH technical support for pre-service institutions, curriculum
revision and long-term training is evident in the diminishing numbers of
public health professionals and upper level managers. The concept of
'twinning' with US-based university programs for long-term training is
also considered at a diminished level, thereby lessening the supply of
cadres such as trained public health professionals.

**Conclusion**

Strategic planning and management of complex health delivery systems
need knowledgeable, skilled leaders and technically competent experts.
Policies directing GH investments in these areas require reexamination.
Supply mechanisms for assuring quality performance within professional
and leadership ranks need attention.

Highly technical/clinical information could be accessed through a
reestablishment of twinning with US universities. Support for twinning
US universities with selected regional university centers of excellence
for long-term training would expand this resource base in more
cost-efficient and practical ways.

Pre-service curriculum revision involves a longer-term commitment than
is found in in-service interventions. Its value however is in the long
term rewards it produces when revisions attend to the tasks and
technical requirements of health care challenges of today that also can
accommodate those of the future. Appropriate introduction of newer
education approaches, e.g. computer-based programs, distance learning,
would also strengthen reform endeavors. Changes in health professional
pre-service curricula and education methodologies will understandingly
require approval from Ministries of Education.

GH partnership and collaboration with country-based training and
educational institutions have diminished over the years. Additionally,
US-based universities have seen their presence diminish within countries
and GH education stipends for health professionals, e.g. public health,
at US universities has all but disappeared. South-to-South institutional
partnering has often been discussed as ideal yet actual agreements
between identified centers of excellence seem to be few if any. Field
office respondents reported that the following institutions could be
potential "centers of excellence" sites:

French: Benin Institute for PH, Diop Medical School in Senegal

English: Makere University in Uganda, Nairobi University, Kenya
(nursing) Universities in Eastern Cape, South Africa (clinical
management, nursing).

#### Recommendation

> [Recommendation 12]{.underline}: Recommit to pre-service education and
> long-term training with emphasis on supporting regional and
> south-to-south educational and training institutions and US twinning
> mechanisms.
>
> [Recommendation 13]{.underline}: In order to effectively address HCD
> policy reforms and restructuring, USAID needs to be working not only
> with Ministries of Health, but also possibly with Ministries of
> Finance (for education funding), Ministries of Education (for nursing
> and medical education), and Ministries of Labor (for remuneration
> levels, incentive structures, and conditions of work).

# 

# Leadership

**Finding: HCD Category/Cadre**

A leadership layer of expert, well-practiced HCD leaders and managers
does not appear to exist within any of the countries contacted, neither
at central nor decentralized levels. Decentralization was described by
several of the field and GH staff as providing opportunities for
developing and strengthening HCD systems and the development of HCD
managers at multiple local sites. It must be noted however, that the
jury is not yet in as to the full ramifications affected through
decentralization. HCD activities were reported in such illustrative
areas as logistics management (Ghana), team supervision problem solving
(Malawi, Egypt, Nicaragua), work-load planning (Zambia, Armenia).
However, no respondents reported broad scale training or mentoring of
HCD managers and no one reported HCD in pre-service curriculum. One
respondent felt that pharmaceutical logistics management should be
introduced into pharmacy schools curricula. In South Africa, one of the
universities has an established certificate program for health
professionals in management, a potential South-to-South resource for HCD
professional development.

**Conclusion**

HCD knowledge and skills are not currently being fostered to develop a
critical mass of experts in host countries sufficient to deal with
prevailing HCD issues. GH through its CA structure and country field
experiences has collected a body of HCD knowledge and practices that
could be shared across office lines in an effort to initiate progress in
this area.

However, sustainable HCD changes cannot be achieved nor maintained
without good leadership and management. In its leadership capacity, the
primary role of GH regarding HCD involves advocating for (championing)
HCD in Mission programming and also in CA agreements. GH advocacy for
HCD to be effective needs placement at the senior level.

#### 

#### In appropriate settings, pre-service educational changes and curricula revisions directed toward inclusion of HCD seem warranted, albeit with longer-term investments. Country and regional settings for these interventions would assure greater investment returns than would investment in US-based training (e.g., in terms of personnel retention, return of students, cheaper and closer accessibility to institutions, and more relevant learning experiences). 

#### Recommendation

> [Recommendation 14]{.underline}: Pre-service education and in-service
> training in HCD management should be initiated to develop a critical
> mass of managers dealing with prevailing HCD issues.

#### 

#### Finding: Cooperating Agencies, PHN Field and GH Staff

HCD leadership qualities and technical expertise within CAs were
described by field and GH respondents as ranging from non-existent to
limited. As previously noted, often CAs were described as not always
responsive to Mission strategic objectives. CA activities in contacted
countries were often seen to be repetitive in nature. The approaches
were interpreted as being "off the shelf" (e.g., in-service training and
supervision models) and not addressing the complexity of the country's
HCD problems.

On the other hand, (1) GH staff generally described Mission staff as
wanting in vision in and ability to judge HCD needs while (2) field
staff was unsure as to GH scope of technical assistance capacity in HCD.
The interviewers found a number of field staff that once made aware of
this evaluation's scope of work and the HCD typology being applied, did
indeed recognize their HCD needs and current status of activities.
However, they often felt that their options for sourcing appropriate
technical input were limited.

Sharing HCD experience and active collaboration among organizations is
not currently being done. Bringing many of the GH technical expertise
areas (e.g. quality assurance, performance improvement, curriculum
design, training of trainers, management and supervision) together to
collectively resolve service provider performance dilemmas would begin
to ensure strengthened HCD systems supportive to various program
achievements.

Another leadership layer that is wanting is GH internal and CA technical
assistance capacity in HCD. Several respondents stated that GH CAs do
not have a systems perspective, e.g. training skills but not skills in
development of training management systems. Additionally, some GH staff
are not well versed in technical aspects of HCD approaches, e.g.
performance improvement, workforce planning, as well as sensitive to the
matching of a given approach to a prevailing situation. These technical
assistance shortcomings seem to be contributing to the lack of progress
in HCD and the development of leaders and managers in the field.

#### Conclusion

Increasing the general awareness level of HCD in the staffs of CA
organizations, PHN field and GH is warranted. Mutual confidence in HCD
knowledge and technical capacity needs to be bolstered. And the dilemma
of differing perceptions of CA functions in field operations needs to be
clarified to the satisfaction first of field offices, and then the CAs
and their CTOs and Technical Advisors (TA).

**Recommendations**

> [Recommendation 15]{.underline}: Increase general awareness of HCD
> issues within GH and across CA organizations and establish
> consultative mechanisms for sharing project experiences and
> identifying best practices including those from Maximizing Access to
> Quality (MAQ), performance improvement (PI), and quality assurance
> (QA).
>
> [Recommendation 16]{.underline}: Clarity of language in CA annual work
> plans is highly desirable regarding the range and type of CA efforts
> in HCD. This would bolster awareness and confidence regarding HCD
> capacities within CA organizations and throughout the CA community.

# 

# Partnerships

**Finding: Donor Coordination in HCD**

Few respondents reported actual partnering with other donors in the HCD
sphere (e.g., the World Bank, EU, DIFD or CIDA). Most reported that
other donors are present in countries, but that their degree of activity
is mostly at the interest level and not necessarily at the action level.
The potential for donor partnering is reported to be within the HCD
components of personnel administration (salaries paid) and integration
of HR and health system objectives (civil service reform).

US organizations were also identified as either having presence or the
potential for in-country partnering, e.g. Centers for Disease Control
(CDC), Health and Human Services (HHS), National Institutes of Health
(NIH), western US foundations-Gates, Hewlett, Packard. Several
respondents were concerned by the lack of consistent GH senior-level
participation in discussions with these organizations to assure that
USAID is seen and acknowledged for its technical assistance capacity.

**Conclusion**

Donors such as the World Bank (WB) and the European Union (EU) have
mechanisms for direct financial assistance and could provide
complimentary technical assistance in these component areas. Substantive
liaisons between USAID/GH and potential partners would greatly increase
the success factor for substantial sustainable HCD changes. It goes
without saying that any HCD initiatives must be developed and
implemented in full consultation with host country representatives and
organizations.

Active involvement related to HCD with crucial US based organizations is
warranted at a time of rapidly changing Agency priorities and mandates.
Participation may well need to be at a senior management level to assure
that both the administrative and programmatic interests of GH are well
represented.

**Recommendations**

[Recommendation 17]{.underline}: Host country representatives and
organizations should be considered full partners in developing and
implementing any HCD initiatives.

> [Recommendation 18]{.underline}: Substantive liaison between USAID GH
> and potential partners such as the WB, WHO, and EU would greatly
> increase the potential for success in HCD.
>
> [Recommendation 19]{.underline}: Participation at senior management
> levels with other US organizations (e.g., CDC, NIH, and HHS) is
> required for administrative and programmatic partnering in health HCD
> efforts.

##### Overarching Recommendation

GH should develop an HCD Strategy that articulates HCD needs and
identifies the scope and depth of priority HCD initiatives GH may be
prepared to support (within each office and jointly). This strategy
should be guided by USAID's programmatic experience, current technical
capabilities, and careful assessments of the potential for success. The
strategy should discuss mechanisms for strengthening USAID's leadership
role in HCD, both through bilateral project assistance and through
collaboration with relevant multilateral organizations.

######### IV. THE WAY FORWARD: OPTIONS FOR FUTURE

######### GH INITIATIVE IN HCD

***Initial Steps for Consideration by the GH Task Force on HCD***

Based upon the conclusions and recommendations of this evaluation, the
GH Task Force on HCD may want to consider the following options as
potential next steps. It should be noted at the outset that the proposed
initiatives outlined below must be predicated on the formulation of an
HCD strategy. Once this strategy has been adopted, future GH action in
HCD will require that GH address the following three issues:

> 1\. The identification of a person (or persons) who will be seen as
> well qualified in HCD issues and readily identified as the 'champion'
> of GH HCD efforts. Concerted advocacy for HCD changes within existing
> and future programs is critical to future success.
>
> 2\. The need to secure staff support for GH's HCD strategy and future
> programmatic agendas.
>
> 3\. Liaise and/or partner with domestic organizations (e.g., CDC, HHS,
> and US foundations) and international donors (e.g., WB, EU, DFID, and
> CIDA) on HCD issues. (As noted in Recommendation 20, liaison
> representation in HCD should be undertaken at senior management
> levels.)

**Integrated HCD Country Initiative**

In addition to developing an HCD Strategy, an important next step for
the GH Task Force would be the implementation of an Integrated HCD
Country Initiative. This activity would address priority HCD needs in a
selected number of countries where the potential for programmatic action
appears promising. The objective of this initiative would be to field
test various HCD initiatives in diverse country environments in order to
identify successful models for action, best practices in HCD, and
interventions that appear to have good potential for replicability.

[Initial work required]{.underline}:

> 1\. In order to better identify current HCD technical capacities that
> can be readily accessed by USAID (and as input for the GH HCD
> Strategic Plan), request CAs to prepare short statements of their
> technical capabilities that speak directly to the five HCD Components
> presented in Table 1.
>
> 2\. Consult with USAID field offices to identify HCD priorities and
> promising opportunities for HCD programming. Several Population,
> Health, Nutrition (PHN) officers interviewed in this evaluation have
> indicated preliminary interest in programming for HCD, i.e. Cambodia,
> South Africa, Uganda, Kenya, and Malawi. Although not interviewed,
> Zambia appears to have interest and potential.
>
> 3\. In countries identified as providing promising opportunities for
> HCD work, undertake systematic assessments of HCD conditions covering
> the five HCD components in Table 1. These assessments should be
> undertaken in collaboration with USAID field missions and should be
> informed by discussions with relevant host country
> counterparts/organizations and other donors actively working in HCD.
>
> 4\. Based upon the HCD information gathered, identify country-specific
> HCD priorities with USAID Missions in order to prepare concrete
> actionable plans for addressing these needs.

In order to undertake this Integrated HCD Country Initiative, GH will
need to access new resources and technical competencies. There are
several options that the GH Task Force should consider in deciding how
this might be accomplished.

[Pre-Requisites for an Integrated Initiative:]{.underline}

> 1\. Form an internal GH HCD Working Group or Unit for the Integrated
> HCD Country Initiative. This body would contain several staff assigned
> to the Working Group full-time plus input from additional staff from
> the Offices of PRH, OHA, HIDN, and RCS. The Working Group would assume
> a coordinating role in interacting with field missions and would
> expedite communication between the field and the organization(s)
> designated to implement this activity.
>
> [Or Alternatively:]{.underline}
>
> 2\. Outsource the functions of the HCD Working Group to an external
> agency that would liaise with GH (specifically the GH Task Force and
> GH Country Coordinators for countries participating in the Initiative)
> and arrange for appropriate technical assistance through
> sub-contracts.

An implementing body for this activity could be selected through a new
competitive procurement. This might entail one of the following three
options:

> 1\. Identify a single CA with experience in HCD process areas to
> implement the Integrated HCD Country Initiative. This CA would
> collaborate with existing CA organizations for specific HCD content
> when required, (e.g. training and education, performance improvement,
> quality assurance, management, and commodity procurement) or by
> drawing upon current mandates and ongoing activities/contracts already
> resident in the CA community. The drawing on current mandates would
> likely offer fast mobilization of a broad range of HCD technical
> expertise in the CA community, but it could also entail recasting
> existing contractual arrangements and commitments that might be time
> consuming and administratively difficult to enact.)
>
> 2\. Identify a small consortium of CAs to act as partners in
> implementing the Integrated HCD Country Initiative. This partnership
> would be responsible for both HCD process and content areas. This
> option as well as the option above assumes that the full range of HCD
> technical competencies required to address widely varied country needs
> can be accessed exclusively from the CA community.
>
> 3\. Identify an implementation mechanism for the Initiative that would
> tap into both CA and university-based communities for technical
> support. This option would draw upon the technical strengths of
> selected CAs and also provide access to specialized expertise and
> longer-term training opportunities primarily available through
> university-based educational facilities in the United States.

# Additional Thoughts for Consideration by the GH Task Force on HCD

**Review the Status of GH's Internal and Contractual Mechanisms**

**for Supporting Long-Term Training in the United States**

It is not clear to the Evaluation Team what mechanisms currently exist
within GH for supporting long-term degree training in the population and
health sciences. We did learn that at least one mission (Malawi) was
sending several people to the United States for long-term degree
training in health, but the mechanism for doing this wasn't clear. Given
that GH may want to provide more long-term training opportunities in the
future, it would be useful to commission a short internal review of
current administrative mechanisms (both internal to GH and through
outside agencies supported by USAID) that could provide greater clarity
regarding the steps GH would need to consider if it chooses to become
more active in supporting long-term training. In particular, it would be
useful to review the current status of the Office of Professional and
Career Development within GH and the Professional Leadership Program
(PLP) as potential mechanisms for collaborating more extensively with
Missions in supporting long-term training and coordinating future
"twinning" efforts with US-based educational institutions.

**Evaluate the Potential of Professional Exchange Programs**

**and Collaboratives in Health**

USAID is currently supporting several professional exchange programs in
health that deserve further scrutiny as potential models for
implementing HCD in the future. One potential model is the American
International Health Alliance (AIHA) that partners American and foreign
medical facilities and staff to collaborate on upgrading specific skill
sets. AIHA's valuable work in Russia on neonatal resuscitation comes to
mind. This mechanism has proven to be highly effective in promoting good
collegial exchange, although its cost may inhibit widespread
replicability in the developing world. We also heard much talk about the
concept of "collaboratives" in which health professionals in the Untied
States and developing countries exchange knowledge and information on
best practices through long-distance learning technologies. This model
has not been widely assessed as yet, and might currently be frustrated
in many developing country settings with poor Internet connectivity.
However, as technology advances, collaboratives could well become
central features of any HCD strategy.

**Position USAID to Assume a More Prominent**

**Global Leadership Role in HCD for Health**

During this evaluation, our attention was drawn to initiatives of the WB
and WHO in HCD. The Bank's HCD efforts tend to be country-based and
integrated with their support for health sector reform and SWAP
mechanisms. The WHO has an active interest in human resource development
and workforce planning (e.g., through WHO's Global Health Workforce
Strategy Group). However, WHO's involvement in HCD tends to be more at
the theoretical and conceptual level, with recommended actions often
under-resourced and inadequately implemented.

The GH Task Force on HCD should consider ways to become more pro-active
in multilateral organizations (particularly WHO and UNICEF) both in
terms of the provision of financial resources and technical assistance.
USAID could be playing a far greater multilateral leadership role in HCD
than is the case at present. Given the broad sweep of HCD issues and the
potentially invasive nature of some HCD reforms that potentially impinge
on national sovereignty sensitivities (e.g., efforts in civil service
reform), it may well be the case that a strong multilateral effort in
HCD could offer the most effective way forward.

## APPENDIX I

**[Scope of Work for HCD Task Force Consultant]{.underline}**

7/1/03

**Background**

[Need]{.underline}

Human Capacity Development and human resource issues have been a problem
in less developed countries for a long time. Health personnel to
population ratios in Africa have been high and have always lagged behind
the rest of the world. In the 1980s, the ratio was 1 doctor to 10, 800
people in comparison to 1:1,400 in other developing countries and 1/300
in industrial countries. During the same period the nurse to population
ratio was 1:2,100 in Africa; 1:1,700 in all developing countries and
1:170 in industrial countries. Through the 1990's and into 2000, there
is evidence to suggest that this has not been resolved, but in fact
gotten worse. There are approximately ten countries in Africa that have
doctor population ratio of 1:30,000.[^2]

In addition to an inadequate number of trained health workers, there are
other factors that contribute to the human capacity dilemma. The number
of new workers entering the health system is insufficient to meet the
need of the population; this is especially true in Sub-Saharan Africa.
In places like Malawi[^3], secondary schools are unable to graduate
enough candidates for medical, nursing or midwifery school. Furthermore,
the underfunding of medical and nursing education has had a negative
effect on the quality of the training graduates receive. When you
consider these phenomena in the context of the number of health workers
who retire, get retrenched, take advantage of voluntary retirement
packages, go abroad for better employment opportunities or get sick from
AIDS and eventually die, the numbers issue is overwhelming.

Apart from the number of health workers, the quality of their training
and length of service, there are concerns about the workers who are
functioning within the health system. Many public sector employees are
under paid. Except in relatively wealthier countries like South Africa
and Botswana, most African governments have salary levels that are
generally low.[^4] Not only are salaries low, in some cases they are not
given on time. In addition to worker compensation, there are concerns
around other motivational factors such as promotion and advancement
opportunities, worker deployment, as well as environmental conditions
like lack of equipment, drugs and supplies.

USAID has a long history in successfully dealing with many of these
human capacity development issues. There have been extensive investments
in training, both pre and in-service, as well as supplying equipment and
other essential supplies. However, the advent of the HIV/AIDS epidemic
has had a dramatic effect on human capacity, forcing people to look
closer at some of these critical issues that effect all health sectors.
One of many examples would be the fact that in many high-prevalence
countries the responsibilities of many FP/RH providers has shifted away
from FP service delivery and more towards the provision of HIV-related
services.

[HCD Task Force]{.underline}

Recognizing the pressing problems of human capacity the senior
management team of the global bureau asked staff within the bureau to
form a task force to examine key human capacity development issues and
determine possible interventions for the global bureau. This task force
is chaired by a representative from the Office of HIV/AIDS (OHA), and
has representatives from the Office of Population and Reproductive
Health (OPRH), Health, Infectious Diseases and Nutrition (HIDN), and the
Office of Regional and Country Support (RCS).

[What is Human Capacity Development?]{.underline}

There are many definitions of the term human capacity development (HCD).
For the purposes of the HCD task force and this assignment the HCD is
defined as:

> "Developing the will, skills, abilities and Human Resource Management
> (HRM) systems to enable people to effectively provide health
> services."

The HCD task force identifies four critical components of action for HCD
activities: they are: legal, policy and financial requirements; human
resource management (HRM); leadership and partnerships. The three
spheres of action are the:

-   individual, family & community

-   provision of services (the focus of this SOW)

-   allocation of resources and policy

**Purpose of this consultancy**

The purpose of this consultancy is to present a series of options to the
HCD task force related to USAID's manageable interest regarding, type,
extent and level of involvement in HCD in the health sector as it
relates to service delivery. The task force will then take this
information and make recommendations to the senior management team.

Two POPTECH consultants with prior experiences in human capacity
development projects will be needed to carry out the assignment.

A Population Leadership Program fellow will act as the facilitator
during the Human Capacity Development Task Force Meeting on July 11,
2003.

**Specific Activities for this assignment:**

1.  Organize and facilitate a retreat for HCD tasks force members. The
    purpose of this retreat will be to finalize the questions that will
    be asked of missions, CAs and GH staff in response to their current
    HCD activities. A list of both GH project countries and missions
    needs to be determined as well. Some illustrative questions could
    be:

    -   What is currently being done in HCD now?

    -   What is the impact of the HIV/AIDS crisis on other health
        sectors?

    -   Are there any success stories? What are they? Why have they been
        successful?

    -   Is HCD an issue for the mission? If so, what are the most
        pressing needs to missions re: HCD?

    -   What can the global bureau do to solve these problems?

> The second part of the purpose is to facilitate an exercise that
> reviews, revises where needed the goals and objectives of the HCD task
> force.

2.  Using the HCD framework, conduct a survey of global health and
    bilateral projects to determine what is being done in HCD. Below is
    an illustrative list of potential global bureau projects for the
    consultant to contact:

  ---------------------- --------------------- --------------------------
  Deliver                Policy II             Advance Africa

  Catalyst               JHPIEGO/TRH           Engender Health

  Intrah                 Youthnet              Call to Action -- EGPAF

  Synergy                PHR+                  QAWD

  IMPACT                 HIV/AIDS Alliance     BASICS

  JHPIEGO/MNH                                  
  ---------------------- --------------------- --------------------------

For the global projects this could be done by contacting the various
CTOs/STAs as well as the CAs themselves. For the bilateral projects, the
first point of contact should be the country coordinators, bureau staff
and then the missions. Key bilateral countries are Ethiopia, South
Africa, Tanzania, and Uganda. Also, the HCD task force began to look at
the HCD activities in 7 countries: Malawi, Zambia, Rwanda, Kenya, Egypt,
Cambodia and Honduras.

3.  Make a series of recommendations (in the forms of options) to the
    task force as to how the global bureaus should support HCD in the
    future.

**Timeline:**

-   Background reading and planning: 4-5 days

-   Task force retreat: 1 day

-   Information gathering: 10-15 days

-   Report writing presentation preparation: 5-10 days

> **Please see Human Capacity Development assignment calendar.**
>
> **[Total level of effort: POPTECH consultants 23-28
> days]{.underline}**

**Deliverables:**

1.  Facilitate and document a 1 day retreat for the HCD task force.

2.  Two 60 minute presentations discussing the findings of this
    assignment. One presentation will be to the HCD working group and
    the second to a broader audience determined at a later date.

3.  A written report -- to be tentatively POPTECH edited.

**Background Reading/background material:**

1.  The Health Sector Human Resource Crisis in Africa: An Issues Paper

2.  Country-specific work done by HCD Task force members

3.  MSH/M&L HCD Presentation

**APPENDIX II**

**Persons Interviewed**

**[USAID/Washington, Global Health Bureau]{.underline}**

Margaret Neuse, Director-Office of Population & Reproductive Health

Gary Newton, Director-Office of Regional & Country Support

Constance Carrino, Director-Office of HIV/AIDS

Willa Pressman, Africa Team Leader, Office of Regional & Country Support

######## Global Health Bureau, Cognizant Technical Officers/Technical Advisors

Tony Boni, MSH/RPM

Dennis Carroll, Infectious Disease Specialist, Office of Health,
Infectious

Disease and Nutrition

Elizabeth Fox, BASICS II

Jim Griffin, JHPIEGO/TRH

Jim Heiby, URC/QAWF

Karen Kavanaugh, PRH+/Abt

Debbie Kosko, PRIME II

Maureen Norton, CATALYST

Jessica Pollak, EngenderHealth

Marne Sommers, MSH/RPM

Susan Wright, MSH/M&L

**[Global Health Bureau, Country Coordinators]{.underline}**

Celeste Carr, South Africa

Frances Davidson, Senegal

Robert Emrey, Chief-Division of Health Systems & Country Coordinator;
Egypt

Joyce Holfeld, Nigeria

Gerry Jennings, Uganda

Pam Mandel, Ukraine

Nancy McCharen, Senegal

Mark Rilling, Indonesia

Liz Schoenecker, Cambodia

Barbara Seligman, Bangladesh

Patricia Stephenson, Zambia

Wyman Stone, Malawi

Dana Vogel, Chief-Division of Service Delivery Improvement and

Country Coordinator; Kenya

**[Cooperating Agency Representatives]{.underline}**

Lynn Bakamjian, EngenderHealth

Mona Byrkit, PRIME II

Joseph Dwyer, MSH/M&L

Barbara Felling, JSI/Deliver

Kama Garrison, JHPIEGO/TRH

Dan Kraushaar, BASICS II

Ron McCarick, JHPIEGO/TRH

Edgar Necocchea, JHPIEGO/TRH

David Nicholas, URC/QAWF

Mary O'Neil, MSH/M&L

Nancy Pielemeier, PRH+/Abt

Cathy Solter, Catalyst/Pathfinder Intl.

**[USAID/Missions]{.underline}**

Ali Abdelmegeid, Egypt

Felix Awantang, Senegal

John Crowley, South Africa

Robert Cunnane, Uganda

Jeannie Friedmann, Bangladesh

Nancy Godfrey, Ukraine

Cheryl Kamin, Malawi

Monica Kerrigan, Indonesia

Mike Strong, Kenya

Mark White, Cambodia

APPENDIX III

HCD Survey Results

USAID Country Coordinator and Mission Responses

+----------+---------+---------+---------+--------+--------+--------+
| Table 1: |         |         |         |        |        |        |
| How      |         |         |         |        |        |        |
| would    |         |         |         |        |        |        |
| you      |         |         |         |        |        |        |
| char     |         |         |         |        |        |        |
| acterize |         |         |         |        |        |        |
| trends   |         |         |         |        |        |        |
| in       |         |         |         |        |        |        |
| pe       |         |         |         |        |        |        |
| r-capita |         |         |         |        |        |        |
| avai     |         |         |         |        |        |        |
| lability |         |         |         |        |        |        |
| of       |         |         |         |        |        |        |
| health   |         |         |         |        |        |        |
| service  |         |         |         |        |        |        |
| p        |         |         |         |        |        |        |
| roviders |         |         |         |        |        |        |
| in your  |         |         |         |        |        |        |
| host     |         |         |         |        |        |        |
| country  |         |         |         |        |        |        |
| by       |         |         |         |        |        |        |
| ge       |         |         |         |        |        |        |
| ographic |         |         |         |        |        |        |
| area     |         |         |         |        |        |        |
| over the |         |         |         |        |        |        |
| past     |         |         |         |        |        |        |
| decade?  |         |         |         |        |        |        |
+----------+---------+---------+---------+--------+--------+--------+
|          | Greatly | D       | R       | Im     | G      | Re     |
|          | Deter   | eclined | emained | proved | reatly | sponse |
|          | iorated |         |         |        |        |        |
|          |         | S       | Same    |        | Im     | Total  |
|          |         | omewhat |         |        | proved |        |
+----------+---------+---------+---------+--------+--------+--------+
| Country  |         |         |         |        |        |        |
| Coo      |         |         |         |        |        |        |
| rdinator |         |         |         |        |        |        |
+----------+---------+---------+---------+--------+--------+--------+
| Urban    | 0%      | 33%     | 17%     | 33%    | 17%    | 6      |
+----------+---------+---------+---------+--------+--------+--------+
| Rural    | 17%     | 33%     | 33%     | 17%    | 0%     | 6      |
+----------+---------+---------+---------+--------+--------+--------+
| National | 0%      | 50%     | 33%     | 0%     | 17%    | 6      |
+----------+---------+---------+---------+--------+--------+--------+
| USAID    |         |         |         |        |        |        |
| Mission  |         |         |         |        |        |        |
+----------+---------+---------+---------+--------+--------+--------+
| Urban    | 22%     | 22%     | 11%     | 33%    | 11%    | 9      |
+----------+---------+---------+---------+--------+--------+--------+
| Rural    | 44%     | 22%     | 0%      | 33%    | 0%     | 9      |
+----------+---------+---------+---------+--------+--------+--------+
| National | 33%     | 33%     | 0%      | 33%    | 0%     | 9      |
+----------+---------+---------+---------+--------+--------+--------+

+----------+---------+---------+---------+--------+--------+--------+
| Table 2: |         |         |         |        |        |        |
| How      |         |         |         |        |        |        |
| would    |         |         |         |        |        |        |
| you      |         |         |         |        |        |        |
| char     |         |         |         |        |        |        |
| acterize |         |         |         |        |        |        |
| trends   |         |         |         |        |        |        |
| in       |         |         |         |        |        |        |
| pe       |         |         |         |        |        |        |
| r-capita |         |         |         |        |        |        |
| avai     |         |         |         |        |        |        |
| lability |         |         |         |        |        |        |
| of       |         |         |         |        |        |        |
| health   |         |         |         |        |        |        |
| service  |         |         |         |        |        |        |
| p        |         |         |         |        |        |        |
| roviders |         |         |         |        |        |        |
| in your  |         |         |         |        |        |        |
| host     |         |         |         |        |        |        |
| country  |         |         |         |        |        |        |
| by       |         |         |         |        |        |        |
| program  |         |         |         |        |        |        |
| element  |         |         |         |        |        |        |
| over the |         |         |         |        |        |        |
| past     |         |         |         |        |        |        |
| decade?  |         |         |         |        |        |        |
+----------+---------+---------+---------+--------+--------+--------+
|          | Greatly | D       | R       | Im     | G      | Re     |
|          | Deter   | eclined | emained | proved | reatly | sponse |
|          | iorated |         |         |        |        |        |
|          |         | S       | Same    |        | Im     | Total  |
|          |         | omewhat |         |        | proved |        |
+----------+---------+---------+---------+--------+--------+--------+
| Country  |         |         |         |        |        |        |
| Coo      |         |         |         |        |        |        |
| rdinator |         |         |         |        |        |        |
+----------+---------+---------+---------+--------+--------+--------+
| FP       | 0%      | 40%     | 40%     | 20%    | 0%     | 5      |
+----------+---------+---------+---------+--------+--------+--------+
| Other RH | 0%      | 20%     | 40%     | 40%    | 0%     | 5      |
+----------+---------+---------+---------+--------+--------+--------+
| HIV/AIDS | 0%      | 20%     | 0%      | 80%    | 0%     | 5      |
+----------+---------+---------+---------+--------+--------+--------+
| MCH      | 20%     | 20%     | 20%     | 40%    | 0%     | 5      |
+----------+---------+---------+---------+--------+--------+--------+
| ID       | 0%      | 40%     | 0%      | 60%    | 0%     | 5      |
+----------+---------+---------+---------+--------+--------+--------+
| N        | 20%     | 20%     | 20%     | 40%    | 0%     | 5      |
| utrition |         |         |         |        |        |        |
+----------+---------+---------+---------+--------+--------+--------+
| USAID    |         |         |         |        |        |        |
| Mission  |         |         |         |        |        |        |
+----------+---------+---------+---------+--------+--------+--------+
| FP       | 22%     | 22%     | 44%     | 11%    | 0%     | 9      |
+----------+---------+---------+---------+--------+--------+--------+
| Other RH | 11%     | 22%     | 33%     | 33%    | 0%     | 9      |
+----------+---------+---------+---------+--------+--------+--------+
| HIV/AIDS | 22%     | 11%     | 33%     | 33%    | 0%     | 9      |
+----------+---------+---------+---------+--------+--------+--------+
| MCH      | 22%     | 44%     | 0%      | 22%    | 11%    | 9      |
+----------+---------+---------+---------+--------+--------+--------+
| ID       | 22%     | 44%     | 0%      | 33%    | 0%     | 9      |
+----------+---------+---------+---------+--------+--------+--------+
| N        | 33%     | 22%     | 11%     | 33%    | 0%     | 9      |
| utrition |         |         |         |        |        |        |
+----------+---------+---------+---------+--------+--------+--------+

+-------------+-------------+-------------+-------------+-------------+
| Table 3:    |             |             |             |             |
| Has the     |             |             |             |             |
| impact of   |             |             |             |             |
| HIV/AIDS    |             |             |             |             |
| increased   |             |             |             |             |
| the need to |             |             |             |             |
| train more  |             |             |             |             |
| service     |             |             |             |             |
| providers   |             |             |             |             |
| in your     |             |             |             |             |
| country?    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Greatly     | Increased   | No Effect   | Response    |
|             | Increased   | Need        |             | Total       |
|             | Need        | Somewhat    |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Country     | 17%         | 67%         | 17%         | 6           |
| Coordinator |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| USAID       | 67%         | 22%         | 11%         | 9           |
|             |             |             |             |             |
| Mission     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 4: Has    |                |                |                 |
| your country    |                |                |                 |
| asked for       |                |                |                 |
| assistance in   |                |                |                 |
| addressing      |                |                |                 |
| future HCD      |                |                |                 |
| needs in health |                |                |                 |
| service         |                |                |                 |
| delivery?       |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| Country         | 40%            | 60%            | 5               |
|                 |                |                |                 |
| Coordinator     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| USAID           | 89%            | 11%            | 9               |
|                 |                |                |                 |
| Mission         |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-----------------+----------------+----------------+-----------------+
| Table 5: In     |                |                |                 |
| your country,   |                |                |                 |
| are there HCD   |                |                |                 |
| strategies in   |                |                |                 |
| place that      |                |                |                 |
| allocate        |                |                |                 |
| resources for   |                |                |                 |
| health service  |                |                |                 |
| providers?      |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| Country         | 60%            | 40%            | 5               |
|                 |                |                |                 |
| Coordinator     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| USAID           | 56%            | 44%            | 9               |
|                 |                |                |                 |
| Mission         |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-------------+-------------+-------------+-------------+-------------+
| Table 5a:   |             |             |             |             |
| If yes, do  |             |             |             |             |
| specific    |             |             |             |             |
| strategies  |             |             |             |             |
| exist for   |             |             |             |             |
| meeting     |             |             |             |             |
| future      |             |             |             |             |
| needs in    |             |             |             |             |
| the         |             |             |             |             |
| following   |             |             |             |             |
| health      |             |             |             |             |
| program     |             |             |             |             |
| areas?      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Yes         | No          | Don't Know  | Response    |
|             |             |             |             | Total       |
+-------------+-------------+-------------+-------------+-------------+
| Country     |             |             |             |             |
| Coordinator |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| FP          | 100%        | 0%          | 0%          | 3           |
+-------------+-------------+-------------+-------------+-------------+
| Other RH    | 67%         | 33%         | 0%          | 3           |
+-------------+-------------+-------------+-------------+-------------+
| HIV/AIDS    | 100%        | 0%          | 0%          | 3           |
+-------------+-------------+-------------+-------------+-------------+
| MCH         | 100%        | 0%          | 0%          | 3           |
+-------------+-------------+-------------+-------------+-------------+
| ID          | 100%        | 0%          | 0%          | 3           |
+-------------+-------------+-------------+-------------+-------------+
| Nutrition   | 67%         | 33%         | 0%          | 3           |
+-------------+-------------+-------------+-------------+-------------+
| USAID       |             |             |             |             |
|             |             |             |             |             |
| Mission     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| FP          | 80%         | 20%         | 0%          | 5           |
+-------------+-------------+-------------+-------------+-------------+
| Other RH    | 60%         | 40%         | 0%          | 5           |
+-------------+-------------+-------------+-------------+-------------+
| HIV/AIDS    | 80%         | 20%         | 0%          | 5           |
+-------------+-------------+-------------+-------------+-------------+
| MCH         | 80%         | 20%         | 0%          | 5           |
+-------------+-------------+-------------+-------------+-------------+
| ID          | 60%         | 40%         | 0%          | 5           |
+-------------+-------------+-------------+-------------+-------------+
| Nutrition   | 80%         | 0%          | 20%         | 5           |
+-------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 5b: If    |                |                |                 |
| no, has there   |                |                |                 |
| been interest   |                |                |                 |
| in developing   |                |                |                 |
| HCD strategies  |                |                |                 |
| for service     |                |                |                 |
| delivery?       |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| Country         | 100%           | 0%             | 2               |
|                 |                |                |                 |
| Coordinator     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| USAID           | 75%            | 25%            | 4               |
|                 |                |                |                 |
| Mission         |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+--------------+-------------+-------------+-------------+-------------+
| Table 6:     |             |             |             |             |
| Does your    |             |             |             |             |
| country have |             |             |             |             |
| specific     |             |             |             |             |
| policies and |             |             |             |             |
| programs     |             |             |             |             |
| that address |             |             |             |             |
| the          |             |             |             |             |
| following    |             |             |             |             |
| HCD          |             |             |             |             |
| components?  |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
|              | Yes         | No          | Don't Know  | Response    |
|              |             |             |             | Total       |
+--------------+-------------+-------------+-------------+-------------+
| Country      |             |             |             |             |
| Coordinator  |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Supply       | 80%         | 20%         | 0%          | 5           |
| System       |             |             |             |             |
|              |             |             |             |             |
| for Health   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Performance  | 40%         | 0%          | 60%         | 5           |
| Management   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Personnel    | 60%         | 20%         | 20%         | 5           |
| Ad           |             |             |             |             |
| ministration |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Educat       | 80%         | 20%         | 0%          | 5           |
| ion/Training |             |             |             |             |
| of Service   |             |             |             |             |
| Providers    |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Integration  | 40%         | 20%         | 40%         | 5           |
| of HR and    |             |             |             |             |
| Health       |             |             |             |             |
| System       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| USAID        |             |             |             |             |
|              |             |             |             |             |
| Mission      |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Supply       | 38%         | 38%         | 25%         | 9           |
| System for   |             |             |             |             |
| Health       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Performance  | 38%         | 50%         | 12%         | 9           |
|              |             |             |             |             |
| Management   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Personnel    | 86%         | 14%         | 0%          | 9           |
|              |             |             |             |             |
| Ad           |             |             |             |             |
| ministration |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Educat       | 75%         | 25%         | 0%          | 9           |
| ion/Training |             |             |             |             |
| of Service   |             |             |             |             |
| Providers    |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Integration  | 38%         | 12%         | 50%         | 9           |
| of HR and    |             |             |             |             |
| Health       |             |             |             |             |
| System       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 7: Does   |                |                |                 |
| the USAID       |                |                |                 |
| mission in your |                |                |                 |
| country         |                |                |                 |
| currently have  |                |                |                 |
| a strategy for  |                |                |                 |
| addressing      |                |                |                 |
| future health   |                |                |                 |
| service         |                |                |                 |
| delivery HCD    |                |                |                 |
| needs?          |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| Country         | 80%            | 20%            | 5               |
|                 |                |                |                 |
| Coordinator     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| USAID           | 50%            | 50%            | 8               |
|                 |                |                |                 |
| Mission         |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-----------------+----------------+----------------+-----------------+
| Table 8: Does   |                |                |                 |
| the USAID       |                |                |                 |
| mission in your |                |                |                 |
| country         |                |                |                 |
| currently have  |                |                |                 |
| a strategy for  |                |                |                 |
| addressing      |                |                |                 |
| future health   |                |                |                 |
| service         |                |                |                 |
| delivery HCD    |                |                |                 |
| needs?          |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| Country         |                |                |                 |
|                 |                |                |                 |
| Coordinator     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| Bilateral       | 100%           | 0%             | 5               |
+-----------------+----------------+----------------+-----------------+
| Central         | 60%            | 40%            | 5               |
+-----------------+----------------+----------------+-----------------+
| USAID           |                |                |                 |
|                 |                |                |                 |
| Mission         |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| Bilateral       | 89%            | 11%            | 9               |
+-----------------+----------------+----------------+-----------------+
| Central         | 67%            | 33%            | 9               |
+-----------------+----------------+----------------+-----------------+

+--------------+-------------+-------------+-------------+-------------+
| Table 9:     |             |             |             |             |
| Which HCD    |             |             |             |             |
| components   |             |             |             |             |
| are being    |             |             |             |             |
| addressed in |             |             |             |             |
| your         |             |             |             |             |
| projects at  |             |             |             |             |
| the present  |             |             |             |             |
| time?        |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
|              | Yes         | No          | Don't Know  | Response    |
|              |             |             |             | Total       |
+--------------+-------------+-------------+-------------+-------------+
| Country      |             |             |             |             |
| Coordinator  |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Supply       | 40%         | 40%         | 20%         | 5           |
| System       |             |             |             |             |
|              |             |             |             |             |
| for Health   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Performance  | 0%          | 50%         | 50%         | 4           |
| Management   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Personnel    | 0%          | 60%         | 40%         | 5           |
| Ad           |             |             |             |             |
| ministration |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Educat       | 100%        | 0%          | 0%          | 5           |
| ion/Training |             |             |             |             |
| of Service   |             |             |             |             |
| Providers    |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Integration  | 20%         | 40%         | 40%         | 5           |
| of HR and    |             |             |             |             |
| Health       |             |             |             |             |
| System       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| USAID        |             |             |             |             |
|              |             |             |             |             |
| Mission      |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Supply       | 50%         | 38%         | 12%         | 8           |
| System       |             |             |             |             |
|              |             |             |             |             |
| for Health   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Performance  | 67%         | 33%         | 0%          | 9           |
|              |             |             |             |             |
| Management   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Personnel    | 50%         | 50%         | 0%          | 8           |
|              |             |             |             |             |
| Ad           |             |             |             |             |
| ministration |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Educat       | 100%        | 0%          | 0%          | 9           |
| ion/Training |             |             |             |             |
| of Service   |             |             |             |             |
| Providers    |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Integration  | 44%         | 44%         | 11%         | 9           |
| of HR and    |             |             |             |             |
| Health       |             |             |             |             |
| System       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 10: Could |                |                |                 |
| your projects   |                |                |                 |
| be doing more   |                |                |                 |
| to strengthen   |                |                |                 |
| service         |                |                |                 |
| delivery HCD at |                |                |                 |
| this time?      |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| Country         | 100%           | 0%             | 5               |
|                 |                |                |                 |
| Coordinator     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| USAID           | 100%           | 0%             | 9               |
|                 |                |                |                 |
| Mission         |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-----------------+----------------+----------------+-----------------+
| Table 11:       |                |                |                 |
| Should USAID    |                |                |                 |
| give greater    |                |                |                 |
| emphasis to     |                |                |                 |
| service         |                |                |                 |
| provider HCD in |                |                |                 |
| the future?     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| Country         | 100%           | 0%             | 5               |
|                 |                |                |                 |
| Coordinator     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| USAID           | 100%           | 0%             | 9               |
|                 |                |                |                 |
| Mission         |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-------------+-------------+-------------+-------------+-------------+
| Table 12:   |             |             |             |             |
| In which    |             |             |             |             |
| sector has  |             |             |             |             |
| your        |             |             |             |             |
| support for |             |             |             |             |
| service     |             |             |             |             |
| provider    |             |             |             |             |
| HCD been    |             |             |             |             |
| most        |             |             |             |             |
| c           |             |             |             |             |
| oncentrated |             |             |             |             |
| over the    |             |             |             |             |
| past five   |             |             |             |             |
| years?      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Public      | Private     | NGOs        | Response    |
|             | Sector      | Sector      |             | Total       |
+-------------+-------------+-------------+-------------+-------------+
| Country     | 100%        | 0%          | 0%          | 5           |
| Coordinator |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| USAID       | 56%         | 0%          | 44%         | 9           |
|             |             |             |             |             |
| Mission     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-------------+-------------+-------------+-------------+-------------+
| Table 13:   |             |             |             |             |
| What        |             |             |             |             |
| priority    |             |             |             |             |
| has been    |             |             |             |             |
| given to    |             |             |             |             |
| each type   |             |             |             |             |
| of service  |             |             |             |             |
| provider in |             |             |             |             |
| your        |             |             |             |             |
| country's   |             |             |             |             |
| training    |             |             |             |             |
| efforts?    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | High        | Medium      | Low         | Response    |
|             | Priority    | Priority    | Priority    | Total       |
+-------------+-------------+-------------+-------------+-------------+
| Country     |             |             |             |             |
| Coordinator |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Doctors     | 0%          | 100%        | 0%          | 5           |
+-------------+-------------+-------------+-------------+-------------+
| Nur         | 80%         | 0%          | 20%         | 5           |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Trad        | 25%         | 50%         | 25%         | 4           |
| Nur         |             |             |             |             |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Paramedics  | 0%          | 50%         | 50%         | 4           |
+-------------+-------------+-------------+-------------+-------------+
| Community   | 0%          | 75%         | 0%          | 4           |
| Workers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Traditional | 0%          | 25%         | 75%         | 4           |
| Healers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| USAID       |             |             |             |             |
|             |             |             |             |             |
| Mission     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Doctors     | 62%         | 25%         | 12%         | 8           |
+-------------+-------------+-------------+-------------+-------------+
| Nur         | 33%         | 67%         | 0%          | 9           |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Trad        | 25%         | 0%          | 75%         | 8           |
| Nur         |             |             |             |             |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Paramedics  | 33%         | 33%         | 33%         | 9           |
+-------------+-------------+-------------+-------------+-------------+
| Community   | 12%         | 62%         | 25%         | 8           |
| Workers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Traditional | 0%          | 25%         | 75%         | 8           |
| Healers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 14: Has   |                |                |                 |
| the             |                |                |                 |
| effectiveness   |                |                |                 |
| of this         |                |                |                 |
| training been   |                |                |                 |
| systematically  |                |                |                 |
| evaluated?      |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| Country         | 40%            | 60%            | 5               |
|                 |                |                |                 |
| Coordinator     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| USAID           | 33%            | 67%            | 9               |
|                 |                |                |                 |
| Mission         |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-----------+----------+-----------+----------+-----------+----------+
| Table     |          |           |          |           |          |
| 14a: If   |          |           |          |           |          |
| yes, how  |          |           |          |           |          |
| would you |          |           |          |           |          |
| rate the  |          |           |          |           |          |
| effe      |          |           |          |           |          |
| ctiveness |          |           |          |           |          |
| of this   |          |           |          |           |          |
| training  |          |           |          |           |          |
| in        |          |           |          |           |          |
| stre      |          |           |          |           |          |
| ngthening |          |           |          |           |          |
| the       |          |           |          |           |          |
| capacity  |          |           |          |           |          |
| to        |          |           |          |           |          |
| deliver   |          |           |          |           |          |
| services  |          |           |          |           |          |
| in your   |          |           |          |           |          |
| country?  |          |           |          |           |          |
+-----------+----------+-----------+----------+-----------+----------+
|           | Highly   | M         | Not Very | Cannot Be | Response |
|           |          | oderately | E        | D         |          |
|           | E        |           | ffective | etermined | Total    |
|           | ffective | Effective |          |           |          |
+-----------+----------+-----------+----------+-----------+----------+
| Country   | 0%       | 100%      | 0%       | 0%        | 2        |
| Co        |          |           |          |           |          |
| ordinator |          |           |          |           |          |
+-----------+----------+-----------+----------+-----------+----------+
| USAID     | 25%      | 50%       | 0%       | 25%       | 4        |
|           |          |           |          |           |          |
| Mission   |          |           |          |           |          |
+-----------+----------+-----------+----------+-----------+----------+

+-------------+-------------+-------------+-------------+-------------+
| Table 15:   |             |             |             |             |
| Are other   |             |             |             |             |
| donors in   |             |             |             |             |
| your        |             |             |             |             |
| country     |             |             |             |             |
| making      |             |             |             |             |
| co          |             |             |             |             |
| ntributions |             |             |             |             |
| to HCD for  |             |             |             |             |
| service     |             |             |             |             |
| providers?  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Yes         | No          | Don't Know  | Response    |
|             |             |             |             | Total       |
+-------------+-------------+-------------+-------------+-------------+
| Country     | 60%         | 0%          | 40%         | 5           |
| Coordinator |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| USAID       | 100%        | 0%          | 0%          | 9           |
|             |             |             |             |             |
| Mission     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-------------+-------------+-------------+-------------+-------------+
| Table 16:   |             |             |             |             |
| Is there    |             |             |             |             |
| donor       |             |             |             |             |
| c           |             |             |             |             |
| oordination |             |             |             |             |
| on HCD      |             |             |             |             |
| issues in   |             |             |             |             |
| your        |             |             |             |             |
| country?    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Yes         | No          | Don't Know  | Response    |
|             |             |             |             | Total       |
+-------------+-------------+-------------+-------------+-------------+
| Country     | 20%         | 40%         | 40%         | 5           |
| Coordinator |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| USAID       | 56%         | 22%         | 22%         | 9           |
|             |             |             |             |             |
| Mission     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-----------+----------+----------+----------+----------+----------+
| Table 17: |          |          |          |          |          |
| In your   |          |          |          |          |          |
| country,  |          |          |          |          |          |
| how would |          |          |          |          |          |
| you rank  |          |          |          |          |          |
| each      |          |          |          |          |          |
| health    |          |          |          |          |          |
| program   |          |          |          |          |          |
| element   |          |          |          |          |          |
| in terms  |          |          |          |          |          |
| of future |          |          |          |          |          |
| demands   |          |          |          |          |          |
| on        |          |          |          |          |          |
| service   |          |          |          |          |          |
| delivery  |          |          |          |          |          |
| HCD?      |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           | High     | Moderate | Low      | No       | Response |
|           |          |          |          |          | Total    |
|           | Demand   | Demand   | Demand   | Demand   |          |
+-----------+----------+----------+----------+----------+----------+
| Country   |          |          |          |          |          |
| Co        |          |          |          |          |          |
| ordinator |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| FP        | 40%      | 20%      | 40%      | 0%       | 5        |
+-----------+----------+----------+----------+----------+----------+
| Other RH  | 60%      | 20%      | 20%      | 0%       | 5        |
+-----------+----------+----------+----------+----------+----------+
| HIV/AIDS  | 60%      | 40%      | 0%       | 0%       | 5        |
+-----------+----------+----------+----------+----------+----------+
| MCH       | 100%     | 0%       | 0%       | 0%       | 5        |
+-----------+----------+----------+----------+----------+----------+
| ID        | 100%     | 0%       | 0%       | 0%       | 5        |
+-----------+----------+----------+----------+----------+----------+
| Nutrition | 60%      | 20%      | 0%       | 20%      | 5        |
+-----------+----------+----------+----------+----------+----------+
| USAID     |          |          |          |          |          |
|           |          |          |          |          |          |
| Mission   |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| FP        | 56%      | 33%      | 11%      | 0%       | 9        |
+-----------+----------+----------+----------+----------+----------+
| Other RH  | 67%      | 33%      | 0%       | 0%       | 9        |
+-----------+----------+----------+----------+----------+----------+
| HIV/AIDS  | 78%      | 22%      | 0%       | 0%       | 9        |
+-----------+----------+----------+----------+----------+----------+
| MCH       | 67%      | 33%      | 0%       | 0%       | 9        |
+-----------+----------+----------+----------+----------+----------+
| ID        | 44%      | 56%      | 0%       | 0%       | 9        |
+-----------+----------+----------+----------+----------+----------+
| Nutrition | 44%      | 33%      | 22%      | 0%       | 0        |
+-----------+----------+----------+----------+----------+----------+

+-------------+-------------+-------------+-------------+-------------+
| Table 18:   |             |             |             |             |
| What type   |             |             |             |             |
| of health   |             |             |             |             |
| worker      |             |             |             |             |
| should      |             |             |             |             |
| receive     |             |             |             |             |
| priority    |             |             |             |             |
| attention   |             |             |             |             |
| in future   |             |             |             |             |
| service     |             |             |             |             |
| delivery    |             |             |             |             |
| HCD efforts |             |             |             |             |
| in your     |             |             |             |             |
| country?    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | High        | Medium      | Low         | Response    |
|             | Priority    | Priority    | Priority    | Total       |
+-------------+-------------+-------------+-------------+-------------+
| Country     |             |             |             |             |
| Coordinator |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Doctors     | 17%         | 67%         | 17%         | 6           |
+-------------+-------------+-------------+-------------+-------------+
| Nur         | 83%         | 17%         | 0%          | 6           |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Trad        | 50%         | 50%         | 0%          | 4           |
| Nur         |             |             |             |             |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Paramedics  | 40%         | 20%         | 40%         | 5           |
+-------------+-------------+-------------+-------------+-------------+
| Community   | 60%         | 40%         | 0%          | 5           |
| Workers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Traditional | 25%         | 50%         | 25%         | 4           |
| Healers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| USAID       |             |             |             |             |
|             |             |             |             |             |
| Mission     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Doctors     | 56%         | 44%         | 0%          | 9           |
+-------------+-------------+-------------+-------------+-------------+
| Nur         | 100%        | 0%          | 0%          | 9           |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Trad        | 33%         | 33%         | 33%         | 9           |
| Nur         |             |             |             |             |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Paramedics  | 44%         | 44%         | 11%         | 9           |
+-------------+-------------+-------------+-------------+-------------+
| Community   | 67%         | 22%         | 11%         | 9           |
| Workers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Traditional | 12%         | 38%         | 50%         | 8           |
| Healers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-----------+----------+-----------+-----------+----------+----------+
| Table 19: |          |           |           |          |          |
| How would |          |           |           |          |          |
| you rank  |          |           |           |          |          |
| the       |          |           |           |          |          |
| i         |          |           |           |          |          |
| mportance |          |           |           |          |          |
| of the    |          |           |           |          |          |
| following |          |           |           |          |          |
| common    |          |           |           |          |          |
| HCD       |          |           |           |          |          |
| service   |          |           |           |          |          |
| provider  |          |           |           |          |          |
| i         |          |           |           |          |          |
| mbalances |          |           |           |          |          |
| in your   |          |           |           |          |          |
| country?  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
|           | Greatly  | M         | Low       | Not      | Response |
|           |          | oderately | I         |          |          |
|           | I        |           | mportance | I        | Total    |
|           | mportant | Important |           | mportant |          |
+-----------+----------+-----------+-----------+----------+----------+
| Country   |          |           |           |          |          |
| Co        |          |           |           |          |          |
| ordinator |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 0%       | 33%       | 33%       | 33%      | 3        |
| New       |          |           |           |          |          |
| Entrants  |          |           |           |          |          |
| to Total  |          |           |           |          |          |
| Provider  |          |           |           |          |          |
| Stock Too |          |           |           |          |          |
| Low       |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 33%      | 33%       | 33%       | 0%       | 3        |
| Sp        |          |           |           |          |          |
| ecialists |          |           |           |          |          |
| to        |          |           |           |          |          |
| Ge        |          |           |           |          |          |
| neralists |          |           |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 33%      | 33%       | 33%       | 0%       | 3        |
|           |          |           |           |          |          |
| Doctors   |          |           |           |          |          |
| to Nurses |          |           |           |          |          |
| Too       |          |           |           |          |          |
|           |          |           |           |          |          |
| High      |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 0%       | 33%       | 67%       | 0%       | 3        |
| Nurses to |          |           |           |          |          |
| Auxiliary |          |           |           |          |          |
| Nurse     |          |           |           |          |          |
| /Midwives |          |           |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 25%      | 25%       | 50%       | 0%       | 4        |
| Urban to  |          |           |           |          |          |
| Rural     |          |           |           |          |          |
| Providers |          |           |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio     | 0%       | 33%       | 33%       | 33%      | 3        |
| Emigrant  |          |           |           |          |          |
| to        |          |           |           |          |          |
| Retained  |          |           |           |          |          |
| Providers |          |           |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| USAID     |          |           |           |          |          |
|           |          |           |           |          |          |
| Mission   |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 38%      | 25%       | 25%       | 12%      | 8        |
| New       |          |           |           |          |          |
| Entrants  |          |           |           |          |          |
| to Total  |          |           |           |          |          |
| Provider  |          |           |           |          |          |
| Stock Too |          |           |           |          |          |
| Low       |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 12%      | 12%       | 62%       | 12%      | 8        |
| Sp        |          |           |           |          |          |
| ecialists |          |           |           |          |          |
| to        |          |           |           |          |          |
| Ge        |          |           |           |          |          |
| neralists |          |           |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 25%      | 38%       | 25%       | 12%      | 8        |
|           |          |           |           |          |          |
| Doctors   |          |           |           |          |          |
| to Nurses |          |           |           |          |          |
| Too       |          |           |           |          |          |
|           |          |           |           |          |          |
| High      |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 25%      | 38%       | 25%       | 12%      | 8        |
| Nurses to |          |           |           |          |          |
| Auxiliary |          |           |           |          |          |
| Nurse     |          |           |           |          |          |
| /Midwives |          |           |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | 62%      | 25%       | 12%       | 0%       | 8        |
| Urban to  |          |           |           |          |          |
| Rural     |          |           |           |          |          |
| Providers |          |           |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio     | 12%      | 0%        | 25%       | 62%      | 8        |
| Emigrant  |          |           |           |          |          |
| to        |          |           |           |          |          |
| Retained  |          |           |           |          |          |
| Providers |          |           |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+

  ----------------------------- ------------- ------------- ------------- -------------
  Table 20: How would you rank                                            
  the importance of the                                                   
  following service delivery                                              
  HCD issues in your country?                                             

                                High Priority Medium        Low Priority  Response
                                              Priority                    Total

  Country Coordinator                                                     

  Staff Recruitment             0%            80%           20%           5

  Staff Deployment              50%           25%           25%           4

  Career Development            60%           40%           0%            5

  Staff Retention               40%           40%           20%           5

  Staff Appraisal               0%            100%          0%            4

  Time/Attend Reporting         0%            50%           50%           4

  Employee Incentives           80%           20%           0%            5

  Service Conditions            50%           50%           0%            4

  Terms of Employment           75%           25%           0%            4

  Pre-Service Training          25%           75%           0%            4

  In-Service Training           60%           40%           0%            5

  Certification/Accreditation   40%           60%           0%            5

  Civil Service Reform          100%          0%            0%            4

  Workload Planning             50%           50%           0%            4

  Training HR Specialists       50%           50%           0%            4

  USAID Mission                                                           

  Staff Recruitment             33%           44%           22%           9

  Staff Deployment              44%           33%           11%           9

  Career Development            44%           56%           0%            9

  Staff Retention               67%           11%           22%           9

  Staff Appraisal               56%           44%           0%            9

  Time/Attend Reporting         50%           12%           38%           8

  Employee Incentives           62%           38%           0%            8

  Conditions of Service         88%           12%           0%            8

  Terms of Employment           75%           25%           0%            8

  Pre-Service Training          78%           22%           0%            9

  In-Service Training           78%           22%           0%            9

  Certification/Accreditation   78%           11%           11%           9

  Civil Service Reform          44%           44%           11%           9

  Workload Planning             50%           38%           12%           8

  Training HR Specialists       38%           38%           25%           8
  ----------------------------- ------------- ------------- ------------- -------------

+-----------------+------------+------------+------------+------------+
| Table 21: In    |            |            |            |            |
| your opinion,   |            |            |            |            |
| what is the     |            |            |            |            |
| likelihood      |            |            |            |            |
| (probability)   |            |            |            |            |
| that USAID      |            |            |            |            |
| resources and   |            |            |            |            |
| technical       |            |            |            |            |
| assistance      |            |            |            |            |
| could be        |            |            |            |            |
| effective in    |            |            |            |            |
| changing        |            |            |            |            |
| policies and    |            |            |            |            |
| practices in    |            |            |            |            |
| the following   |            |            |            |            |
| HCD areas given |            |            |            |            |
| your host       |            |            |            |            |
| country         |            |            |            |            |
| political,      |            |            |            |            |
| regulatory, and |            |            |            |            |
| legal           |            |            |            |            |
| environments?   |            |            |            |            |
+-----------------+------------+------------+------------+------------+
|                 | High       | Moderate   | Low        | Response   |
|                 |            |            |            |            |
|                 | P          | P          | P          | Total      |
|                 | robability | robability | robability |            |
+-----------------+------------+------------+------------+------------+
| Country         |            |            |            |            |
| Coordinator     |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Staff           | 0%         | 60%        | 40%        | 5          |
| Recruitment     |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Staff           | 0%         | 20%        | 80%        | 5          |
| Deployment      |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Career          | 0%         | 40%        | 60%        | 5          |
| Development     |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Staff Retention | 0%         | 20%        | 80%        | 5          |
+-----------------+------------+------------+------------+------------+
| Staff Appraisal | 0%         | 40%        | 60%        | 5          |
+-----------------+------------+------------+------------+------------+
| Time/Attend     | 0%         | 20%        | 80%        | 5          |
| Reporting       |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Employee        | 0%         | 100%       | 0%         | 5          |
| Incentives      |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Service         | 20%        | 20%        | 60%        | 5          |
| Conditions      |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Terms of        | 0%         | 20%        | 80%        | 5          |
| Employment      |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Pre-Service     | 33%        | 50%        | 17%        | 6          |
| Training        |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| In-Service      | 33%        | 67%        | 0%         | 6          |
| Training        |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Certificatio    | 50%        | 33%        | 17%        | 6          |
| n/Accreditation |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Civil Service   | 20%        | 0%         | 80%        | 5          |
| Reform          |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Workload        | 17%        | 17%        | 67%        | 6          |
| Planning        |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Training HR     | 20%        | 60%        | 20%        | 5          |
| Specialists     |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| USAID Mission   |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Staff           | 11%        | 22%        | 67%        | 9          |
| Recruitment     |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Staff           | 33%        | 11%        | 56%        | 9          |
| Deployment      |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Career          | 33%        | 44%        | 22%        | 9          |
| Development     |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Staff Retention | 0%         | 22%        | 78%        | 9          |
+-----------------+------------+------------+------------+------------+
| Staff Appraisal | 11%        | 44%        | 44%        | 9          |
+-----------------+------------+------------+------------+------------+
| Time/Attend     | 0%         | 22%        | 78%        | 9          |
| Reporting       |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Employee        | 0%         | 33%        | 67%        | 9          |
| Incentives      |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Conditions of   | 11%        | 44%        | 44%        | 9          |
| Service         |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Terms of        | 0%         | 33%        | 67%        | 9          |
| Employment      |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Pre-Service     | 67%        | 22%        | 11%        | 9          |
| Training        |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| In-Service      | 78%        | 22%        | 0%         | 9          |
| Training        |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Certificatio    | 44%        | 56%        | 0%         | 9          |
| n/Accreditation |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Civil Service   | 0%         | 33%        | 67%        | 9          |
| Reform          |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Workload        | 11%        | 56%        | 33%        | 9          |
| Planning        |            |            |            |            |
+-----------------+------------+------------+------------+------------+
| Training HR     | 44%        | 11%        | 44%        | 9          |
| Specialists     |            |            |            |            |
+-----------------+------------+------------+------------+------------+

APPENDIX IV

HCD Survey Results

USAID CTO and CA Representative Responses

+---------+---------+---------+---------+---------+---------+---------+
| Table   |         |         |         |         |         |         |
| 1: How  |         |         |         |         |         |         |
| would   |         |         |         |         |         |         |
| you     |         |         |         |         |         |         |
| chara   |         |         |         |         |         |         |
| cterize |         |         |         |         |         |         |
| trends  |         |         |         |         |         |         |
| in      |         |         |         |         |         |         |
| per     |         |         |         |         |         |         |
| -capita |         |         |         |         |         |         |
| avail   |         |         |         |         |         |         |
| ability |         |         |         |         |         |         |
| of      |         |         |         |         |         |         |
| health  |         |         |         |         |         |         |
| service |         |         |         |         |         |         |
| pr      |         |         |         |         |         |         |
| oviders |         |         |         |         |         |         |
| in your |         |         |         |         |         |         |
| co      |         |         |         |         |         |         |
| untries |         |         |         |         |         |         |
| by      |         |         |         |         |         |         |
| geo     |         |         |         |         |         |         |
| graphic |         |         |         |         |         |         |
| area    |         |         |         |         |         |         |
| over    |         |         |         |         |         |         |
| the     |         |         |         |         |         |         |
| past    |         |         |         |         |         |         |
| decade? |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         | Greatly | D       | R       | I       | Greatly | R       |
|         | Deter   | eclined | emained | mproved |         | esponse |
|         | iorated |         |         |         | I       |         |
|         |         | S       | Same    |         | mproved | Total   |
|         |         | omewhat |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| USAID   |         |         |         |         |         |         |
| CTO     |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| Urban   | 25%     | 50%     | 25%     | 0%      | 0%      | 4       |
+---------+---------+---------+---------+---------+---------+---------+
| Rural   | 50%     | 25%     | 0%      | 25%     | 0%      | 4       |
+---------+---------+---------+---------+---------+---------+---------+
| N       | 25%     | 50%     | 0%      | 25%     | 0%      | 4       |
| ational |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| CA      |         |         |         |         |         |         |
|         |         |         |         |         |         |         |
| Rep     |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| Urban   | 22%     | 22%     | 11%     | 44%     | 0%      | 9       |
+---------+---------+---------+---------+---------+---------+---------+
| Rural   | 33%     | 22%     | 33%     | 11%     | 0%      | 9       |
+---------+---------+---------+---------+---------+---------+---------+
| N       | 22%     | 22%     | 22%     | 33%     | 0%      | 9       |
| ational |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+

+---------+---------+---------+---------+---------+---------+---------+
| Table   |         |         |         |         |         |         |
| 2: How  |         |         |         |         |         |         |
| would   |         |         |         |         |         |         |
| you     |         |         |         |         |         |         |
| chara   |         |         |         |         |         |         |
| cterize |         |         |         |         |         |         |
| trends  |         |         |         |         |         |         |
| in      |         |         |         |         |         |         |
| per     |         |         |         |         |         |         |
| -capita |         |         |         |         |         |         |
| avail   |         |         |         |         |         |         |
| ability |         |         |         |         |         |         |
| of      |         |         |         |         |         |         |
| health  |         |         |         |         |         |         |
| service |         |         |         |         |         |         |
| pr      |         |         |         |         |         |         |
| oviders |         |         |         |         |         |         |
| by      |         |         |         |         |         |         |
| program |         |         |         |         |         |         |
| element |         |         |         |         |         |         |
| in the  |         |         |         |         |         |         |
| co      |         |         |         |         |         |         |
| untries |         |         |         |         |         |         |
| where   |         |         |         |         |         |         |
| your    |         |         |         |         |         |         |
| organ   |         |         |         |         |         |         |
| ization |         |         |         |         |         |         |
| (CA)    |         |         |         |         |         |         |
| has     |         |         |         |         |         |         |
| been    |         |         |         |         |         |         |
| working |         |         |         |         |         |         |
| over    |         |         |         |         |         |         |
| the     |         |         |         |         |         |         |
| past    |         |         |         |         |         |         |
| decade? |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         | Greatly | D       | R       | I       | Greatly | R       |
|         | Deter   | eclined | emained | mproved |         | esponse |
|         | iorated |         |         |         | I       |         |
|         |         | S       | Same    |         | mproved | Total   |
|         |         | omewhat |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| USAID   |         |         |         |         |         |         |
|         |         |         |         |         |         |         |
| CTO     |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| FP      | 50%     | 0%      | 50%     | 0%      | 0%      | 4       |
+---------+---------+---------+---------+---------+---------+---------+
| Other   | 50%     | 25%     | 25%     | 0%      | 0%      | 4       |
| RH      |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| H       | 25%     | 25%     | 0%      | 50%     | 0%      | 4       |
| IV/AIDS |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| MCH     | 25%     | 25%     | 25%     | 25%     | 0%      | 4       |
+---------+---------+---------+---------+---------+---------+---------+
| ID      | 25%     | 25%     | 25%     | 25%     | 0%      | 4       |
+---------+---------+---------+---------+---------+---------+---------+
| Nu      | 33%     | 67%     | 0%      | 0%      | 0%      | 3       |
| trition |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| CA      |         |         |         |         |         |         |
|         |         |         |         |         |         |         |
| Rep     |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| FP      | 0%      | 62%     | 25%     | 12%     | 0%      | 8       |
+---------+---------+---------+---------+---------+---------+---------+
| Other   | 0%      | 50%     | 12%     | 38%     | 0%      | 8       |
| RH      |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| H       | 12%     | 12%     | 12%     | 62%     | 0%      | 8       |
| IV/AIDS |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| MCH     | 11%     | 22%     | 44%     | 22%     | 0%      | 9       |
+---------+---------+---------+---------+---------+---------+---------+
| ID      | 11%     | 22%     | 22%     | 44%     | 0%      | 9       |
+---------+---------+---------+---------+---------+---------+---------+
| Nu      | 11%     | 44%     | 33%     | 11%     | 0%      | 9       |
| trition |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+

+-------------+-------------+-------------+-------------+-------------+
| Table 3:    |             |             |             |             |
| Has the     |             |             |             |             |
| impact of   |             |             |             |             |
| HIV/AIDS    |             |             |             |             |
| increased   |             |             |             |             |
| the need to |             |             |             |             |
| train more  |             |             |             |             |
| service     |             |             |             |             |
| providers   |             |             |             |             |
| in your     |             |             |             |             |
| countries?  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Greatly     | Increased   | No Effect   | Response    |
|             | Increased   | Need        |             | Total       |
|             | Need        | Somewhat    |             |             |
+-------------+-------------+-------------+-------------+-------------+
| USAID       | 60%         | 40%         | 0%          | 5           |
|             |             |             |             |             |
| CTO         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| CA          | 89%         | 11%         | 0%          | 9           |
|             |             |             |             |             |
| Rep         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 4: Have   |                |                |                 |
| your countries  |                |                |                 |
| asked for       |                |                |                 |
| assistance in   |                |                |                 |
| addressing      |                |                |                 |
| future HCD      |                |                |                 |
| needs in health |                |                |                 |
| service         |                |                |                 |
| delivery?       |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| USAID           | 100%           | 0%             | 5               |
|                 |                |                |                 |
| CTO             |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| CA              | 88%            | 13%            | 8               |
|                 |                |                |                 |
| Rep             |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-----------------+----------------+----------------+-----------------+
| Table 5: In     |                |                |                 |
| your host       |                |                |                 |
| countries, are  |                |                |                 |
| there HCD       |                |                |                 |
| strategies in   |                |                |                 |
| place that      |                |                |                 |
| allocate        |                |                |                 |
| resources for   |                |                |                 |
| health service  |                |                |                 |
| providers?      |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| USAID           | 50%            | 50%            | 4               |
|                 |                |                |                 |
| CTO             |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| CA              | 33%            | 67%            | 9               |
|                 |                |                |                 |
| Rep             |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-------------+-------------+-------------+-------------+-------------+
| Table 5a:   |             |             |             |             |
| If yes, do  |             |             |             |             |
| specific    |             |             |             |             |
| strategies  |             |             |             |             |
| exist for   |             |             |             |             |
| meeting     |             |             |             |             |
| future      |             |             |             |             |
| needs in    |             |             |             |             |
| the         |             |             |             |             |
| following   |             |             |             |             |
| health      |             |             |             |             |
| program     |             |             |             |             |
| areas?      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Yes         | No          | Don't Know  | Response    |
|             |             |             |             | Total       |
+-------------+-------------+-------------+-------------+-------------+
| USAID       |             |             |             |             |
|             |             |             |             |             |
| CTO         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| FP          | 100%        | 0%          | 0%          | 2           |
+-------------+-------------+-------------+-------------+-------------+
| Other RH    | 50%         | 0%          | 50%         | 2           |
+-------------+-------------+-------------+-------------+-------------+
| HIV/AIDS    | 50%         | 0%          | 50%         | 2           |
+-------------+-------------+-------------+-------------+-------------+
| MCH         | 50%         | 0%          | 50%         | 2           |
+-------------+-------------+-------------+-------------+-------------+
| ID          | 0%          | 0%          | 100%        | 2           |
+-------------+-------------+-------------+-------------+-------------+
| Nutrition   | 0%          | 0%          | 100%        | 2           |
+-------------+-------------+-------------+-------------+-------------+
| CA          |             |             |             |             |
|             |             |             |             |             |
| Rep         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| FP          | 33%         | 33%         | 33%         | 3           |
+-------------+-------------+-------------+-------------+-------------+
| Other RH    | 33%         | 0%          | 67%         | 3           |
+-------------+-------------+-------------+-------------+-------------+
| HIV/AIDS    | 100%        | 0%          | 0%          | 3           |
+-------------+-------------+-------------+-------------+-------------+
| MCH         | 67%         | 0%          | 33%         | 3           |
+-------------+-------------+-------------+-------------+-------------+
| ID          | 33%         | 0%          | 67%         | 3           |
+-------------+-------------+-------------+-------------+-------------+
| Nutrition   | 0%          | 0%          | 100%        | 3           |
+-------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 5b: If    |                |                |                 |
| no, has there   |                |                |                 |
| been interest   |                |                |                 |
| in developing   |                |                |                 |
| HCD strategies  |                |                |                 |
| for service     |                |                |                 |
| delivery?       |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| USAID           | 100%           | 0%             | 2               |
|                 |                |                |                 |
| CTO             |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| CA              | 67%            | 33%            | 6               |
|                 |                |                |                 |
| Rep             |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+--------------+-------------+-------------+-------------+-------------+
| Table 6: Do  |             |             |             |             |
| your         |             |             |             |             |
| countries    |             |             |             |             |
| have         |             |             |             |             |
| specific     |             |             |             |             |
| policies and |             |             |             |             |
| programs     |             |             |             |             |
| that address |             |             |             |             |
| the          |             |             |             |             |
| following    |             |             |             |             |
| HCD          |             |             |             |             |
| components?  |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
|              | Yes         | No          | Don't Know  | Response    |
|              |             |             |             | Total       |
+--------------+-------------+-------------+-------------+-------------+
| USAID        |             |             |             |             |
|              |             |             |             |             |
| CTO          |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Supply       | 40%         | 20%         | 40%         | 5           |
| System       |             |             |             |             |
|              |             |             |             |             |
| for Health   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Performance  | 20%         | 80%         | 0%          | 5           |
| Management   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Personnel    | 40%         | 20%         | 40%         | 5           |
| Ad           |             |             |             |             |
| ministration |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Educat       | 60%         | 40%         | 0%          | 5           |
| ion/Training |             |             |             |             |
| of Service   |             |             |             |             |
| Providers    |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Integration  | 20%         | 60%         | 20%         | 5           |
| of HR and    |             |             |             |             |
| Health       |             |             |             |             |
| System       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| CA           |             |             |             |             |
|              |             |             |             |             |
| Rep          |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Supply       | 33%         | 44%         | 22%         | 9           |
| System for   |             |             |             |             |
| Health       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Performance  | 22%         | 56%         | 22%         | 9           |
|              |             |             |             |             |
| Management   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Personnel    | 44%         | 44%         | 11%         | 9           |
|              |             |             |             |             |
| Ad           |             |             |             |             |
| ministration |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Educat       | 56%         | 44%         | 0%          | 9           |
| ion/Training |             |             |             |             |
| of Service   |             |             |             |             |
| Providers    |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Integration  | 0%          | 67%         | 33%         | 9           |
| of HR and    |             |             |             |             |
| Health       |             |             |             |             |
| System       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 7: Do the |                |                |                 |
| USAID missions  |                |                |                 |
| in your         |                |                |                 |
| countries       |                |                |                 |
| currently have  |                |                |                 |
| strategies for  |                |                |                 |
| addressing      |                |                |                 |
| future health   |                |                |                 |
| service         |                |                |                 |
| delivery HCD    |                |                |                 |
| needs?          |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| USAID           | 60%            | 40%            | 5               |
|                 |                |                |                 |
| CTO             |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| CA              | 67%            | 33%            | 9               |
|                 |                |                |                 |
| Rep             |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-----------------+----------------+----------------+-----------------+
| Table 8: Are    |                |                |                 |
| your CA         |                |                |                 |
| projects        |                |                |                 |
| currently       |                |                |                 |
| incorporating   |                |                |                 |
| HCD for service |                |                |                 |
| providers as    |                |                |                 |
| part of their   |                |                |                 |
| overall         |                |                |                 |
| objectives?     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| USAID           | 100%           | 0%             | 5               |
|                 |                |                |                 |
| CTO             |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| CA              | 78%            | 22%            | 9               |
|                 |                |                |                 |
| Rep             |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+--------------+-------------+-------------+-------------+-------------+
| Table 9:     |             |             |             |             |
| Which HCD    |             |             |             |             |
| components   |             |             |             |             |
| are being    |             |             |             |             |
| addressed in |             |             |             |             |
| your         |             |             |             |             |
| projects at  |             |             |             |             |
| the present  |             |             |             |             |
| time?        |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
|              | Yes         | No          | Don't Know  | Response    |
|              |             |             |             | Total       |
+--------------+-------------+-------------+-------------+-------------+
| USAID        |             |             |             |             |
|              |             |             |             |             |
| CTO          |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Supply       | 40%         | 60%         | 0%          | 5           |
| System       |             |             |             |             |
|              |             |             |             |             |
| for Health   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Performance  | 100%        | 0%          | 0%          | 5           |
| Management   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Personnel    | 60%         | 40%         | 0%          | 5           |
| Ad           |             |             |             |             |
| ministration |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Educat       | 100%        | 0%          | 0%          | 5           |
| ion/Training |             |             |             |             |
| of Service   |             |             |             |             |
| Providers    |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Integration  | 60%         | 40%         | 0%          | 5           |
| of HR and    |             |             |             |             |
| Health       |             |             |             |             |
| System       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| CA           |             |             |             |             |
|              |             |             |             |             |
| Rep          |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Supply       | 57%         | 29%         | 14%         | 7           |
| System       |             |             |             |             |
|              |             |             |             |             |
| for Health   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Performance  | 57%         | 43%         | 0%          | 7           |
|              |             |             |             |             |
| Management   |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Personnel    | 29%         | 57%         | 14%         | 7           |
|              |             |             |             |             |
| Ad           |             |             |             |             |
| ministration |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Educat       | 86%         | 14%         | 0%          | 7           |
| ion/Training |             |             |             |             |
| of Service   |             |             |             |             |
| Providers    |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Integration  | 29%         | 57%         | 14%         | 7           |
| of HR and    |             |             |             |             |
| Health       |             |             |             |             |
| System       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 10: Could |                |                |                 |
| your projects   |                |                |                 |
| be doing more   |                |                |                 |
| to strengthen   |                |                |                 |
| service         |                |                |                 |
| delivery HCD at |                |                |                 |
| this time?      |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| USAID           | 100%           | 0%             | 4               |
|                 |                |                |                 |
| CTO             |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| CA              | 89%            | 11%            | 9               |
|                 |                |                |                 |
| Rep             |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-----------------+----------------+----------------+-----------------+
| Table 11:       |                |                |                 |
| Should USAID    |                |                |                 |
| give greater    |                |                |                 |
| emphasis to     |                |                |                 |
| service         |                |                |                 |
| provider HCD in |                |                |                 |
| the future?     |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| USAID           | 80%            | 20%            | 5               |
|                 |                |                |                 |
| CTO             |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| CA              | 89%            | 11%            | 9               |
|                 |                |                |                 |
| Rep             |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+-------------+-------------+-------------+-------------+-------------+
| Table 12:   |             |             |             |             |
| In which    |             |             |             |             |
| sector has  |             |             |             |             |
| your        |             |             |             |             |
| org         |             |             |             |             |
| anization's |             |             |             |             |
| (CA's)      |             |             |             |             |
| support for |             |             |             |             |
| service     |             |             |             |             |
| provider    |             |             |             |             |
| HCD been    |             |             |             |             |
| most        |             |             |             |             |
| c           |             |             |             |             |
| oncentrated |             |             |             |             |
| over the    |             |             |             |             |
| past five   |             |             |             |             |
| years?      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Public      | Private     | NGOs        | Response    |
|             | Sector      | Sector      |             | Total       |
+-------------+-------------+-------------+-------------+-------------+
| USAID       | 100%        | 0%          | 0%          | 5           |
|             |             |             |             |             |
| CTO         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| CA          | 88.9        | 0%          | 11%         | 9           |
|             |             |             |             |             |
| Rep         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-------------+-------------+-------------+-------------+-------------+
| Table 13:   |             |             |             |             |
| What        |             |             |             |             |
| priority    |             |             |             |             |
| has been    |             |             |             |             |
| given to    |             |             |             |             |
| each type   |             |             |             |             |
| of service  |             |             |             |             |
| provider in |             |             |             |             |
| your        |             |             |             |             |
| org         |             |             |             |             |
| anization's |             |             |             |             |
| (CAs)       |             |             |             |             |
| training    |             |             |             |             |
| efforts?    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | High        | Medium      | Low         | Response    |
|             | Priority    | Priority    | Priority    | Total       |
+-------------+-------------+-------------+-------------+-------------+
| USAID       |             |             |             |             |
|             |             |             |             |             |
| CTO         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Doctors     | 20%         | 20%         | 60%         | 5           |
+-------------+-------------+-------------+-------------+-------------+
| Nur         | 0%          | 20%         | 80%         | 5           |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Trad        | 80%         | 20%         | 0%          | 5           |
| Nur         |             |             |             |             |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Paramedics  | 60%         | 20%         | 20%         | 5           |
+-------------+-------------+-------------+-------------+-------------+
| Community   | 100%        | 0%          | 0%          | 5           |
| Workers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Traditional | 100%        | 0%          | 0%          | 5           |
| Healers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| CA          |             |             |             |             |
|             |             |             |             |             |
| Rep         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Doctors     | 33%         | 44%         | 22%         | 9           |
+-------------+-------------+-------------+-------------+-------------+
| Nur         | 78%         | 11%         | 11%         | 9           |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Trad        | 22%         | 22%         | 56%         | 9           |
| Nur         |             |             |             |             |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Paramedics  | 11%         | 44%         | 44%         | 9           |
+-------------+-------------+-------------+-------------+-------------+
| Community   | 33%         | 33%         | 33%         | 9           |
| Workers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Traditional | 0%          | 11%         | 89%         | 9           |
| Healers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-----------------+----------------+----------------+-----------------+
| Table 14: Has   |                |                |                 |
| the             |                |                |                 |
| effectiveness   |                |                |                 |
| of this         |                |                |                 |
| training been   |                |                |                 |
| systematically  |                |                |                 |
| evaluated?      |                |                |                 |
+-----------------+----------------+----------------+-----------------+
|                 | Yes            | No             | Response Total  |
+-----------------+----------------+----------------+-----------------+
| USAID           | 80%            | 20%            | 5               |
|                 |                |                |                 |
| CTO             |                |                |                 |
+-----------------+----------------+----------------+-----------------+
| CA              | 33%            | 67%            | 9               |
|                 |                |                |                 |
| Rep             |                |                |                 |
+-----------------+----------------+----------------+-----------------+

+----------+----------+-----------+----------+-----------+----------+
| Table    |          |           |          |           |          |
| 14a: If  |          |           |          |           |          |
| yes, how |          |           |          |           |          |
| would    |          |           |          |           |          |
| you rate |          |           |          |           |          |
| the      |          |           |          |           |          |
| effec    |          |           |          |           |          |
| tiveness |          |           |          |           |          |
| of this  |          |           |          |           |          |
| training |          |           |          |           |          |
| in       |          |           |          |           |          |
| stren    |          |           |          |           |          |
| gthening |          |           |          |           |          |
| the      |          |           |          |           |          |
| capacity |          |           |          |           |          |
| to       |          |           |          |           |          |
| deliver  |          |           |          |           |          |
| services |          |           |          |           |          |
| in your  |          |           |          |           |          |
| co       |          |           |          |           |          |
| untries? |          |           |          |           |          |
+----------+----------+-----------+----------+-----------+----------+
|          | Highly   | M         | Not Very | Cannot Be | Response |
|          |          | oderately | E        | D         |          |
|          | E        |           | ffective | etermined | Total    |
|          | ffective | Effective |          |           |          |
+----------+----------+-----------+----------+-----------+----------+
| USAID    | 25%      | 75%       | 0%       | 0%        | 4        |
|          |          |           |          |           |          |
| CTO      |          |           |          |           |          |
+----------+----------+-----------+----------+-----------+----------+
| CA       | 100%     | 0%        | 0%       | 0%        | 9        |
|          |          |           |          |           |          |
| Rep      |          |           |          |           |          |
+----------+----------+-----------+----------+-----------+----------+

+-------------+-------------+-------------+-------------+-------------+
| Table 15:   |             |             |             |             |
| Are other   |             |             |             |             |
| donors in   |             |             |             |             |
| your        |             |             |             |             |
| countries   |             |             |             |             |
| making      |             |             |             |             |
| co          |             |             |             |             |
| ntributions |             |             |             |             |
| to HCD for  |             |             |             |             |
| service     |             |             |             |             |
| providers?  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Yes         | No          | Don't Know  | Response    |
|             |             |             |             | Total       |
+-------------+-------------+-------------+-------------+-------------+
| USAID       | 40%         | 0%          | 60%         | 5           |
|             |             |             |             |             |
| CTO         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| CA          | 67%         | 11%         | 22%         | 9           |
|             |             |             |             |             |
| Rep         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-------------+-------------+-------------+-------------+-------------+
| Table 16:   |             |             |             |             |
| Is there    |             |             |             |             |
| donor       |             |             |             |             |
| c           |             |             |             |             |
| oordination |             |             |             |             |
| on HCD      |             |             |             |             |
| issues in   |             |             |             |             |
| your        |             |             |             |             |
| countries?  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | Yes         | No          | Don't Know  | Response    |
|             |             |             |             | Total       |
+-------------+-------------+-------------+-------------+-------------+
| USAID       | 40%         | 0%          | 60%         | 5           |
|             |             |             |             |             |
| CTO         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| CA          | 33%         | 44%         | 22%         | 9           |
|             |             |             |             |             |
| Rep         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-----------+----------+-----------+----------+----------+-----------+
| Table 17: |          |           |          |          |           |
| In your   |          |           |          |          |           |
| c         |          |           |          |          |           |
| ountries, |          |           |          |          |           |
| how would |          |           |          |          |           |
| you rank  |          |           |          |          |           |
| each      |          |           |          |          |           |
| health    |          |           |          |          |           |
| program   |          |           |          |          |           |
| element   |          |           |          |          |           |
| in terms  |          |           |          |          |           |
| of future |          |           |          |          |           |
| demands   |          |           |          |          |           |
| on        |          |           |          |          |           |
| service   |          |           |          |          |           |
| delivery  |          |           |          |          |           |
| HCD?      |          |           |          |          |           |
+-----------+----------+-----------+----------+----------+-----------+
|           | High     | Moderate  | Low      | No       | Response  |
|           |          |           |          |          | Total     |
|           | Demand   | Demand    | Demand   | Demand   |           |
+-----------+----------+-----------+----------+----------+-----------+
| USAID     |          |           |          |          |           |
|           |          |           |          |          |           |
| CTO       |          |           |          |          |           |
+-----------+----------+-----------+----------+----------+-----------+
| FP        | 25%      | 50%       | 25%      | 0%       | 4         |
+-----------+----------+-----------+----------+----------+-----------+
| Other RH  | 0%       | 75%       | 25%      | 0%       | 4         |
+-----------+----------+-----------+----------+----------+-----------+
| HIV/AIDS  | 100%     | 0%        | 0%       | 0%       | 4         |
+-----------+----------+-----------+----------+----------+-----------+
| MCH       | 25%      | 75%       | 0%       | 0%       | 4         |
+-----------+----------+-----------+----------+----------+-----------+
| ID        | 50%      | 50%       | 0%       | 0%       | 4         |
+-----------+----------+-----------+----------+----------+-----------+
| Nutrition | 0%       | 50%       | 50%      | 0%       | 4         |
+-----------+----------+-----------+----------+----------+-----------+
| CA        |          |           |          |          |           |
|           |          |           |          |          |           |
| Rep       |          |           |          |          |           |
+-----------+----------+-----------+----------+----------+-----------+
| FP        | 38%      | 50%       | 12%      | 0%       | 8         |
+-----------+----------+-----------+----------+----------+-----------+
| Other RH  | 62%      | 12%       | 25%      | 0%       | 8         |
+-----------+----------+-----------+----------+----------+-----------+
| HIV/AIDS  | 88%      | 12%       | 0%       | 0%       | 8         |
+-----------+----------+-----------+----------+----------+-----------+
| MCH       | 50%      | 38%       | 12%      | 0%       | 8         |
+-----------+----------+-----------+----------+----------+-----------+
| ID        | 62%      | 25%       | 12%      | 0%       | 8         |
+-----------+----------+-----------+----------+----------+-----------+
| Nutrition | 38%      | 38%       | 25%      | 0%       | 8         |
+-----------+----------+-----------+----------+----------+-----------+

+-------------+-------------+-------------+-------------+-------------+
| Table 18:   |             |             |             |             |
| What type   |             |             |             |             |
| of health   |             |             |             |             |
| worker      |             |             |             |             |
| should      |             |             |             |             |
| receive     |             |             |             |             |
| priority    |             |             |             |             |
| attention   |             |             |             |             |
| in future   |             |             |             |             |
| service     |             |             |             |             |
| delivery    |             |             |             |             |
| HCD efforts |             |             |             |             |
| in your     |             |             |             |             |
| countries?  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | High        | Medium      | Low         | Response    |
|             | Priority    | Priority    | Priority    | Total       |
+-------------+-------------+-------------+-------------+-------------+
| USAID       |             |             |             |             |
|             |             |             |             |             |
| CTO         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Doctors     | 40%         | 40%         | 20%         | 5           |
+-------------+-------------+-------------+-------------+-------------+
| Nur         | 100%        | 0%          | 0%          | 5           |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Trad        | 20%         | 60%         | 20%         | 5           |
| Nur         |             |             |             |             |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Paramedics  | 60%         | 40%         | 0%          | 5           |
+-------------+-------------+-------------+-------------+-------------+
| Community   | 60%         | 40%         | 0%          | 5           |
| Workers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Traditional | 0%          | 20%         | 80%         | 5           |
| Healers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| CA          |             |             |             |             |
|             |             |             |             |             |
| Rep         |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Doctors     | 33%         | 56%         | 11%         | 9           |
+-------------+-------------+-------------+-------------+-------------+
| Nur         | 100%        | 0%          | 0%          | 9           |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Trad        | 56%         | 33%         | 11%         | 9           |
| Nur         |             |             |             |             |
| se/Midwives |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Paramedics  | 56%         | 44%         | 0%          | 9           |
+-------------+-------------+-------------+-------------+-------------+
| Community   | 89%         | 11%         | 0%          | 9           |
| Workers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Traditional | 22%         | 56%         | 22%         | 9           |
| Healers     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+------------+----------+----------+----------+----------+----------+
| Table 19:  |          |          |          |          |          |
| How would  |          |          |          |          |          |
| you rank   |          |          |          |          |          |
| the        |          |          |          |          |          |
| importance |          |          |          |          |          |
| of the     |          |          |          |          |          |
| following  |          |          |          |          |          |
| common HCD |          |          |          |          |          |
| service    |          |          |          |          |          |
| provider   |          |          |          |          |          |
| imbalances |          |          |          |          |          |
| in your    |          |          |          |          |          |
| countries? |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
|            | Greatly  | Mo       | Low      | Not      | Response |
|            |          | derately | Im       |          |          |
|            | I        |          | portance | I        | Total    |
|            | mportant | I        |          | mportant |          |
|            |          | mportant |          |          |          |
+------------+----------+----------+----------+----------+----------+
| USAID      |          |          |          |          |          |
|            |          |          |          |          |          |
| CTO        |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 20%      | 80%      | 0%       | 0%       | 5        |
| New        |          |          |          |          |          |
| Entrants   |          |          |          |          |          |
| to Total   |          |          |          |          |          |
| Provider   |          |          |          |          |          |
| Stock Too  |          |          |          |          |          |
| Low        |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 0%       | 60%      | 40%      | 0%       | 5        |
| S          |          |          |          |          |          |
| pecialists |          |          |          |          |          |
| to         |          |          |          |          |          |
| G          |          |          |          |          |          |
| eneralists |          |          |          |          |          |
| Too High   |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 20%      | 40%      | 0%       | 40%      | 5        |
|            |          |          |          |          |          |
| Doctors to |          |          |          |          |          |
| Nurses Too |          |          |          |          |          |
|            |          |          |          |          |          |
| High       |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 0%       | 50%      | 25%      | 25%      | 5        |
| Nurses to  |          |          |          |          |          |
| Auxiliary  |          |          |          |          |          |
| Nurs       |          |          |          |          |          |
| e/Midwives |          |          |          |          |          |
| Too High   |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 80%      | 20%      | 0%       | 0%       | 5        |
|            |          |          |          |          |          |
| Urban to   |          |          |          |          |          |
| Rural      |          |          |          |          |          |
| Providers  |          |          |          |          |          |
| Too High   |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio      | 25%      | 0%       | 75%      | 0%       | 4        |
| Emigrant   |          |          |          |          |          |
| to         |          |          |          |          |          |
| Retained   |          |          |          |          |          |
| Providers  |          |          |          |          |          |
| Too High   |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| CA         |          |          |          |          |          |
|            |          |          |          |          |          |
| Rep        |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 43%      | 29%      | 29%      | 0%       | 7        |
| New        |          |          |          |          |          |
| Entrants   |          |          |          |          |          |
| to Total   |          |          |          |          |          |
| Provider   |          |          |          |          |          |
| Stock Too  |          |          |          |          |          |
| Low        |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 25%      | 50%      | 25%      | 0%       | 8        |
| S          |          |          |          |          |          |
| pecialists |          |          |          |          |          |
| to         |          |          |          |          |          |
| G          |          |          |          |          |          |
| eneralists |          |          |          |          |          |
| Too High   |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 50%      | 25%      | 25%      | 0%       | 8        |
|            |          |          |          |          |          |
| Doctors to |          |          |          |          |          |
| Nurses Too |          |          |          |          |          |
|            |          |          |          |          |          |
| High       |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 14%      | 43%      | 43%      | 0%       | 7        |
| Nurses to  |          |          |          |          |          |
| Auxiliary  |          |          |          |          |          |
| Nurs       |          |          |          |          |          |
| e/Midwives |          |          |          |          |          |
| Too High   |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio of   | 62%      | 38%      | 0%       | 0%       | 8        |
|            |          |          |          |          |          |
| Urban to   |          |          |          |          |          |
| Rural      |          |          |          |          |          |
| Providers  |          |          |          |          |          |
| Too High   |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+
| Ratio      | 14%      | 43%      | 14%      | 0%       | 7        |
| Emigrant   |          |          |          |          |          |
| to         |          |          |          |          |          |
| Retained   |          |          |          |          |          |
| Providers  |          |          |          |          |          |
| Too High   |          |          |          |          |          |
+------------+----------+----------+----------+----------+----------+

  ----------------------------- ------------ ------------ ------------ ------------
  Table 20: How would you rank                                         
  the importance of the                                                
  following service delivery                                           
  HCD issues in your countries?                                        

                                High         Medium       Low Priority Response
                                Priority     Priority                  Total

  USAID CTO                                                            

  Staff Recruitment             0%           50%          50%          4

  Staff Deployment              100%         0%           0%           4

  Career Development            25%          75%          0%           4

  Staff Retention               50%          25%          25%          4

  Staff Appraisal               75%          0%           25%          4

  Time/Attend Reporting         0%           50%          50%          4

  Employee Incentives           75%          25%          0%           4

  Service Conditions            0%           75%          25%          4

  Terms of Employment           25%          50%          25%          4

  Pre-Service Training          50%          50%          0%           4

  In-Service Training           50%          50%          0%           4

  Certification/Accreditation   25%          75%          0%           4

  Civil Service Reform          25%          50%          25%          4

  Workload Planning             50%          25%          25%          4

  Training HR Specialists       25%          25%          50%          4

  CA Rep                                                               

  Staff Recruitment             44%          33%          22%          9

  Staff Deployment              78%          22%          0%           9

  Career Development            78%          22%          0%           9

  Staff Retention               78%          22%          0%           9

  Staff Appraisal               56%          33%          11%          9

  Time/Attend Reporting         33%          44%          22%          9

  Employee Incentives           89%          11%          0%           9

  Conditions of Service         56%          33%          11%          9

  Terms of Employment           56%          44%          0%           9

  Pre-Service Training          89%          11%          0%           9

  In-Service Training           78%          22%          0%           9

  Certification/Accreditation   65%          33%          11%          9

  Civil Service Reform          56%          33%          11%          9

  Workload Planning             78%          11%          11%          9

  Training HR Specialists       44%          44%          11%          9
  ----------------------------- ------------ ------------ ------------ ------------

+-------------------+-----------+-----------+-----------+-----------+
| Table 21: In your |           |           |           |           |
| opinion, what is  |           |           |           |           |
| the likelihood    |           |           |           |           |
| (probability)     |           |           |           |           |
| that USAID        |           |           |           |           |
| resources and     |           |           |           |           |
| technical         |           |           |           |           |
| assistance could  |           |           |           |           |
| be effective in   |           |           |           |           |
| changing policies |           |           |           |           |
| and practices in  |           |           |           |           |
| the following HCD |           |           |           |           |
| areas given your  |           |           |           |           |
| host country      |           |           |           |           |
| political,        |           |           |           |           |
| regulatory, and   |           |           |           |           |
| legal             |           |           |           |           |
| environments?     |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
|                   | High      | Moderate  | Low       | Response  |
|                   |           |           |           |           |
|                   | Pr        | Pr        | Pr        | Total     |
|                   | obability | obability | obability |           |
+-------------------+-----------+-----------+-----------+-----------+
| USAID CTO         |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Staff Recruitment | 0%        | 0%        | 100%      | 5         |
+-------------------+-----------+-----------+-----------+-----------+
| Staff Deployment  | 0%        | 60%       | 40%       | 5         |
+-------------------+-----------+-----------+-----------+-----------+
| Career            | 0%        | 100%      | 0%        | 5         |
| Development       |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Staff Retention   | 0%        | 40%       | 60%       | 5         |
+-------------------+-----------+-----------+-----------+-----------+
| Staff Appraisal   | 40%       | 60%       | 0%        | 5         |
+-------------------+-----------+-----------+-----------+-----------+
| Time/Attend       | 20%       | 20%       | 60%       | 5         |
| Reporting         |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Employee          | 20%       | 40%       | 40%       | 5         |
| Incentives        |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Service           | 0%        | 80%       | 20%       | 5         |
| Conditions        |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Terms of          | 0%        | 40%       | 60%       | 5         |
| Employment        |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Pre-Service       | 80%       | 20%       | 0%        | 5         |
| Training          |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| In-Service        | 60%       | 40%       | 0%        | 5         |
| Training          |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Certificat        | 60%       | 40%       | 0%        | 5         |
| ion/Accreditation |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Civil Service     | 0%        | 20%       | 80%       | 5         |
| Reform            |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Workload Planning | 40%       | 40%       | 20%       | 5         |
+-------------------+-----------+-----------+-----------+-----------+
| Training HR       | 40%       | 40%       | 20%       | 5         |
| Specialists       |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| CA Rep            |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Staff Recruitment | 22%       | 44%       | 33%       | 9         |
+-------------------+-----------+-----------+-----------+-----------+
| Staff Deployment  | 33%       | 22%       | 44%       | 9         |
+-------------------+-----------+-----------+-----------+-----------+
| Career            | 11%       | 67%       | 22%       | 9         |
| Development       |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Staff Retention   | 0%        | 89%       | 11%       | 9         |
+-------------------+-----------+-----------+-----------+-----------+
| Staff Appraisal   | 33%       | 56%       | 11%       | 9         |
+-------------------+-----------+-----------+-----------+-----------+
| Time/Attend       | 11%       | 56%       | 33%       | 9         |
| Reporting         |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Employee          | 11%       | 56%       | 33%       | 9         |
| Incentives        |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Conditions of     | 0%        | 44%       | 56%       | 9         |
| Service           |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Terms of          | 0%        | 56%       | 44%       | 9         |
| Employment        |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Pre-Service       | 56%       | 33%       | 11%       | 9         |
| Training          |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| In-Service        | 56%       | 33%       | 11%       | 9         |
| Training          |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Certificat        | 67%       | 11%       | 22%       | 9         |
| ion/Accreditation |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Civil Service     | 0%        | 56%       | 33%       | 9         |
| Reform            |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Workload Planning | 33%       | 56%       | 11%       | 9         |
+-------------------+-----------+-----------+-----------+-----------+
| Training HR       | 50%       | 38%       | 12%       | 9         |
| Specialists       |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+

APPENDIX V

Open-Ended Responses to Survey Question 18a: What Are Important HCD
Initiatives to Consider Implementing

+----------------+-----------------------------------------------------+
| What would be  |                                                     |
| important HCD  |                                                     |
| initiatives to |                                                     |
| consider       |                                                     |
| implementing   |                                                     |
| in your        |                                                     |
| country?       |                                                     |
+----------------+-----------------------------------------------------+
| Country        |                                                     |
| Coordinator    |                                                     |
+----------------+-----------------------------------------------------+
| Indonesia      | \- Owing to the country's push to decentralize the  |
|                | delivery of health services, strengthen technical   |
|                | and system capabilities at the regency (kabupaten)  |
|                | level.                                              |
+----------------+-----------------------------------------------------+
|                | \- Address issues pertaining to the quality of care |
|                | and encourage more effective                        |
|                | administration/management of the service delivery   |
|                | system                                              |
+----------------+-----------------------------------------------------+
| Kenya          | \- Promote incentives for RH service providers,     |
|                | better supervision, and efficient workload planning |
|                | (Kenya has lots of staff who don't always have a    |
|                | lot to do).                                         |
+----------------+-----------------------------------------------------+
| South Africa   | \- Recruit and train more nurses. Also consider     |
|                | introducing financial incentives for community      |
|                | health workers.                                     |
+----------------+-----------------------------------------------------+
| USAID Mission  |                                                     |
+----------------+-----------------------------------------------------+
| Bangladesh     | \- More pre and in-service training for skill       |
|                | development. Also place greater emphasis on         |
|                | performance management for community-based service  |
|                | providers.                                          |
+----------------+-----------------------------------------------------+
| Cambodia       | \- Institute salary incentives based on performance |
|                | (government rather than donor driven) and identify  |
|                | and reward achievements among health providers.     |
+----------------+-----------------------------------------------------+
|                | \- Cost recovery initiatives are needed to better   |
|                | fund health services and generate                   |
|                |                                                     |
|                | higher staff salaries and working conditions        |
+----------------+-----------------------------------------------------+
| Egypt          | \- Update medical and nursing school curriculums to |
|                | be more competency-based and oriented toward        |
|                | evidence-based clinical practice.                   |
+----------------+-----------------------------------------------------+
|                | \- Strengthen the teaching and training             |
|                | capabilities of university faculties and MOHP       |
|                | trainers.                                           |
+----------------+-----------------------------------------------------+
|                | \- Develop and update IT applications used by       |
|                | students and professionals in medical and nursing   |
|                | schools.                                            |
+----------------+-----------------------------------------------------+
| Malawai        | \- Support local institutions to increase capacity  |
|                | (e.g., by supporting lecturer/tutor training).      |
+----------------+-----------------------------------------------------+
|                | \- Undertake studies of HR needs (e.g., through     |
|                | situation analysis) and develop specific HR         |
|                | policies and interventions.                         |
+----------------+-----------------------------------------------------+
| Senegal        | \- Provide more training in health program planning |
|                | and system analysis, training in                    |
|                | monitoring/evaluation and specific technical        |
|                | skills.                                             |
+----------------+-----------------------------------------------------+
| Uganda         | \- Focus initially on improving in-service and      |
|                | pre-service training -- we will need to use         |
|                | inefficient vertical training programs until the    |
|                | training system improves.                           |
+----------------+-----------------------------------------------------+
|                | \- Incentives and performance monitoring are        |
|                | critical but cannot be addressed effectively        |
|                | through a health sector program. This is a civil    |
|                | service policy issue.                               |
+----------------+-----------------------------------------------------+
| Ukraine        | \- Civil service reform is most critical, along     |
|                | with reducing the number of physicians trained,     |
|                | increasing the number nurses and support staff.     |
+----------------+-----------------------------------------------------+
|                | \- Greater emphasis needs to be given to primary    |
|                | health care rather than specialized curative        |
|                | services.                                           |
+----------------+-----------------------------------------------------+
|                | \- The health system needs to be rationalized,      |
|                | patients need to pay for services, and health       |
|                | providers need to be paid.                          |
+----------------+-----------------------------------------------------+
|                | \- Health facilities need to be appropriate to need |
|                | (with some hospitals closed), and pharmaceuticals   |
|                | need to be procured and paid for.                   |
+----------------+-----------------------------------------------------+
| Zambia         | \- Greater support to pre-service training and      |
|                | established training institutions instead of the    |
|                | current focus on disease specific in-service        |
|                | training.                                           |
+----------------+-----------------------------------------------------+
|                | \- Technical support to human resources management  |
|                | including recruitment and retention.                |
+----------------+-----------------------------------------------------+
|                | -Participating with national governments in         |
|                | establishing incentive schemes for health workers   |
|                | like home ownership and transportation/loan         |
|                | schemes.                                            |
+----------------+-----------------------------------------------------+
| What would be  |                                                     |
| important HCD  |                                                     |
| initiatives to |                                                     |
| consider       |                                                     |
| implementing   |                                                     |
| in the         |                                                     |
| countries      |                                                     |
| where your     |                                                     |
| organization   |                                                     |
| (CA) is        |                                                     |
| working        |                                                     |
+----------------+-----------------------------------------------------+
| USAID CTO      |                                                     |
+----------------+-----------------------------------------------------+
|                | \- Work with decentralized health regions to        |
|                | improve HCD for all facility-based clinical health  |
|                | care.                                               |
+----------------+-----------------------------------------------------+
|                | \- Go beyond pre/in service training and            |
|                | incorporate more management, supervision, and       |
|                | deployment issues in TA work                        |
+----------------+-----------------------------------------------------+
| CA Rep         |                                                     |
+----------------+-----------------------------------------------------+
|                | \- Better staff recruitment and deployment systems  |
|                | are needed. Encourage motivation and incentive      |
|                | strategies that enhance performance and staff       |
|                | retention.                                          |
+----------------+-----------------------------------------------------+
|                | \- More work in health manpower planning and the    |
|                | identification of future skill sets is needed.      |
+----------------+-----------------------------------------------------+
|                | \- Better protect human capital in the health       |
|                | sector, especially in settings with elevated        |
|                | HIV/AIDS prevalence and high-risk occupations.      |
+----------------+-----------------------------------------------------+
|                | \- Promote quality assurance by giving greater      |
|                | attention to accreditation, certification, and      |
|                | licensing of service providers.                     |
+----------------+-----------------------------------------------------+
|                | \- Improve pre-service curricula so that in-service |
|                | training is eventually needed less.                 |
+----------------+-----------------------------------------------------+
|                | \- Give greater attention to the in-country         |
|                | distribution of staff (in many cases distribution   |
|                | is the problem, not absolute numbers of staff       |
|                | trained).                                           |
+----------------+-----------------------------------------------------+
|                | \- Improve service outreach (again, numbers may not |
|                | be the greatest HR problem) by increasing staff     |
|                | abilities to do outreach.                           |
+----------------+-----------------------------------------------------+
|                | \- USAID's commitment to in-service training needs  |
|                | to be continued while providing more HR management  |
|                | training for supervisors.                           |
+----------------+-----------------------------------------------------+
|                | \- Try out performance appraisal and remuneration   |
|                | systems for improved performance (e.g., performance |
|                | contracting).                                       |
+----------------+-----------------------------------------------------+
|                | \- Much more work is needed on evaluation and       |
|                | operations research to determine the effectiveness  |
|                | of different HCD approaches.                        |
+----------------+-----------------------------------------------------+
|                | \- Greater utilization of on-the-job training and   |
|                | distance learning methods should be promoted in     |
|                | future HCD work.                                    |
+----------------+-----------------------------------------------------+
|                | \- Much HCD work is done outside Ministries of      |
|                | Health. We should be working more with Ministries   |
|                | of Finance (for education funding), Ministries of   |
|                | Education (for nursing and medical education) and   |
|                | Ministries of Labor (for remuneration, incentive    |
|                | structures, deployment, and production policies).   |
+----------------+-----------------------------------------------------+
|                | \- We need to work with various ministries and the  |
|                | private sector in dealing with licensing, tax       |
|                | incentives, drug dispensing, importation            |
|                | regulations, and so on.                             |
+----------------+-----------------------------------------------------+
|                | \- USAID projects do HCD work all the time, but     |
|                | there is no place where this experience is captured |
|                | and reviewed to see what we know and assess new     |
|                | ideas.                                              |
|                |                                                     |
|                | As a result we are spending millions of dollars on  |
|                | training, supervision courses, etc. without knowing |
|                | what others are doing and without rigorous analysis |
|                | of whether it is working. HCD is a critical         |
|                | priority but we don't do it well, we don't          |
|                | coordinate our work, we don't systematically        |
|                | evaluate it, and we don't share experiences (e.g.,  |
|                | best and worst practices). .                        |
+----------------+-----------------------------------------------------+
|                | \- Donor projects tend to focus on the production   |
|                | of health workers, supervision training, and the    |
|                | quality of work done by providers (mainly in the    |
|                | public sector). The real issues in HCD are          |
|                | distribution of health manpower within a country,   |
|                | motivation of workers to perform primarily related  |
|                | to salary and benefits, and drug and supply         |
|                | logistics so that workers have the materials they   |
|                | need to actually perform the work the systems ask   |
|                | of them. We generally don't consider these areas as |
|                | HCD issues, but they are.                           |
+----------------+-----------------------------------------------------+
|                | \- We are all looking for quick fixes/successes.    |
|                | HCD is a long-term but critical thing and it        |
|                | affects everything we do. It's high time we do      |
|                | something, but the probability of doing anything    |
|                | that will have an impact on the short term is low.  |
|                | We should do something, but don't expect quick      |
|                | changes.                                            |
+----------------+-----------------------------------------------------+

APPENDIX VI

Human Capacity Development Needs and Actionable Priorities Reported

by USAID Field Missions

+--------+---------+---------+---------+---------+---------+---------+
| Table  |         |         |         |         |         |         |
| 1: How |         |         |         |         |         |         |
| would  |         |         |         |         |         |         |
| you    |         |         |         |         |         |         |
| charac |         |         |         |         |         |         |
| terize |         |         |         |         |         |         |
| trends |         |         |         |         |         |         |
| in     |         |         |         |         |         |         |
| per-   |         |         |         |         |         |         |
| capita |         |         |         |         |         |         |
| availa |         |         |         |         |         |         |
| bility |         |         |         |         |         |         |
| of     |         |         |         |         |         |         |
| health |         |         |         |         |         |         |
| s      |         |         |         |         |         |         |
| ervice |         |         |         |         |         |         |
| pro    |         |         |         |         |         |         |
| viders |         |         |         |         |         |         |
| in     |         |         |         |         |         |         |
| your   |         |         |         |         |         |         |
| host   |         |         |         |         |         |         |
| c      |         |         |         |         |         |         |
| ountry |         |         |         |         |         |         |
| by     |         |         |         |         |         |         |
| geog   |         |         |         |         |         |         |
| raphic |         |         |         |         |         |         |
| area   |         |         |         |         |         |         |
| over   |         |         |         |         |         |         |
| the    |         |         |         |         |         |         |
| past   |         |         |         |         |         |         |
| d      |         |         |         |         |         |         |
| ecade? |         |         |         |         |         |         |
+--------+---------+---------+---------+---------+---------+---------+
|        | Greatly | D       | R       | I       | Greatly | R       |
|        | Deter   | eclined | emained | mproved |         | esponse |
|        | iorated |         |         |         | I       |         |
|        |         | S       | Same    |         | mproved | Total   |
|        |         | omewhat |         |         |         |         |
+--------+---------+---------+---------+---------+---------+---------+
| USAID  |         |         |         |         |         |         |
| M      |         |         |         |         |         |         |
| ission |         |         |         |         |         |         |
+--------+---------+---------+---------+---------+---------+---------+
| Urban  | Malawi  | Kenya   | Uganda  | Ban     | Egypt   | 9       |
|        |         |         |         | gladesh |         |         |
|        | Zambia  | Senegal |         |         |         |         |
|        |         |         |         | C       |         |         |
|        |         |         |         | ambodia |         |         |
|        |         |         |         |         |         |         |
|        |         |         |         | Ukraine |         |         |
+--------+---------+---------+---------+---------+---------+---------+
| Rural  | Malawi  | Kenya   |         | Ban     |         | 9       |
|        |         |         |         | gladesh |         |         |
|        | Senegal | Ukraine |         |         |         |         |
|        |         |         |         | C       |         |         |
|        | Uganda  |         |         | ambodia |         |         |
|        |         |         |         |         |         |         |
|        | Zambia  |         |         | Egypt   |         |         |
+--------+---------+---------+---------+---------+---------+---------+
| Na     | Malawi  | Kenya   |         | Ban     |         | 9       |
| tional |         |         |         | gladesh |         |         |
|        | Uganda  | Senegal |         |         |         |         |
|        |         |         |         | C       |         |         |
|        | Zambia  | Ukraine |         | ambodia |         |         |
|        |         |         |         |         |         |         |
|        |         |         |         | Egypt   |         |         |
+--------+---------+---------+---------+---------+---------+---------+

+-----------+----------+-----------+----------+----------+----------+
| Table 2:  |          |           |          |          |          |
| How would |          |           |          |          |          |
| you rank  |          |           |          |          |          |
| the       |          |           |          |          |          |
| i         |          |           |          |          |          |
| mportance |          |           |          |          |          |
| of the    |          |           |          |          |          |
| following |          |           |          |          |          |
| common    |          |           |          |          |          |
| HCD       |          |           |          |          |          |
| service   |          |           |          |          |          |
| provider  |          |           |          |          |          |
| i         |          |           |          |          |          |
| mbalances |          |           |          |          |          |
| in your   |          |           |          |          |          |
| country?  |          |           |          |          |          |
+-----------+----------+-----------+----------+----------+----------+
|           | Greatly  | M         | Low      | Not      | Response |
|           |          | oderately | Im       |          |          |
|           | I        |           | portance | I        | Total    |
|           | mportant | Important |          | mportant |          |
+-----------+----------+-----------+----------+----------+----------+
| USAID     |          |           |          |          |          |
|           |          |           |          |          |          |
| Mission   |          |           |          |          |          |
+-----------+----------+-----------+----------+----------+----------+
| Ratio of  | Malawi   | B         | Uganda   | Egypt    | 8        |
| New       |          | angladesh |          |          |          |
| Entrants  | Senegal  |           | Ukraine  |          |          |
| to Total  |          | Cambodia  |          |          |          |
| Provider  | Zambia   |           |          |          |          |
| Stock Too |          |           |          |          |          |
| Low       |          |           |          |          |          |
+-----------+----------+-----------+----------+----------+----------+
| Ratio of  | Ukraine  | Senegal   | Ba       | Malawi   | 8        |
| Sp        |          |           | ngladesh |          |          |
| ecialists |          |           |          | Uganda   |          |
| to        |          |           | Cambodia |          |          |
| Ge        |          |           |          | Zambia   |          |
| neralists |          |           | Egypt    |          |          |
| Too High  |          |           |          |          |          |
+-----------+----------+-----------+----------+----------+----------+
| Ratio of  | Egypt    | B         | Cambodia | Malawi   | 8        |
|           |          | angladesh |          |          |          |
| Doctors   | Zambia   |           |          | Uganda   |          |
| to Nurses |          | Senegal   |          |          |          |
| Too       |          |           |          |          |          |
|           |          | Ukraine   |          |          |          |
| High      |          |           |          |          |          |
+-----------+----------+-----------+----------+----------+----------+
| Ratio of  | Ba       | Cambodia  | Ukraine  | Egypt    | 8        |
| Nurses to | ngladesh |           |          |          |          |
| Auxiliary |          | Senegal   |          | Malawi   |          |
| Nurse     | Zambia   |           |          |          |          |
| /Midwives |          | Uganda    |          |          |          |
| Too High  |          |           |          |          |          |
+-----------+----------+-----------+----------+----------+----------+
| Ratio of  | Ba       | Malawi    | Cambodia |          | 8        |
| Urban to  | ngladesh |           |          |          |          |
| Rural     |          | Ukraine   |          |          |          |
| Providers | Egypt    |           |          |          |          |
| Too High  |          |           |          |          |          |
|           | Senegal  |           |          |          |          |
|           |          |           |          |          |          |
|           | Uganda   |           |          |          |          |
|           |          |           |          |          |          |
|           | Zambia   |           |          |          |          |
+-----------+----------+-----------+----------+----------+----------+
| Ratio     | Zambia   |           | Uganda   | Ba       | 8        |
| Emigrant  |          |           |          | ngladesh |          |
| to        |          |           | Ukraine  |          |          |
| Retained  |          |           |          | Cambodia |          |
| Providers |          |           |          |          |          |
| Too High  |          |           |          | Egypt    |          |
|           |          |           |          |          |          |
|           |          |           |          | Malawi   |          |
|           |          |           |          |          |          |
|           |          |           |          | Senegal  |          |
+-----------+----------+-----------+----------+----------+----------+

+--------------+-------------+-------------+------------+-------------+
| Table 3:     |             |             |            |             |
| Which HCD    |             |             |            |             |
| components   |             |             |            |             |
| are being    |             |             |            |             |
| addressed in |             |             |            |             |
| your         |             |             |            |             |
| projects at  |             |             |            |             |
| the present  |             |             |            |             |
| time?        |             |             |            |             |
+--------------+-------------+-------------+------------+-------------+
|              | Yes         | No          | Don't Know | Response    |
|              |             |             |            | Total       |
+--------------+-------------+-------------+------------+-------------+
| USAID        |             |             |            |             |
|              |             |             |            |             |
| Mission      |             |             |            |             |
+--------------+-------------+-------------+------------+-------------+
| Supply       | Bangladesh  | Kenya       | Ukraine    | 9           |
| System       |             |             |            |             |
|              | Cambodia    | Senegal     |            |             |
| for Health   |             |             |            |             |
|              | Egypt       | Uganda      |            |             |
|              |             |             |            |             |
|              | Malawi      | Zambia      |            |             |
+--------------+-------------+-------------+------------+-------------+
| Performance  | Bangladesh  | Kenya       |            | 9           |
|              |             |             |            |             |
| Management   | Cambodia    | Uganda      |            |             |
|              |             |             |            |             |
|              | Egypt       | Malawi      |            |             |
|              |             |             |            |             |
|              | Senegal     |             |            |             |
|              |             |             |            |             |
|              | Ukraine     |             |            |             |
|              |             |             |            |             |
|              | Zambia      |             |            |             |
+--------------+-------------+-------------+------------+-------------+
| Personnel    | Egypt       | Bangladesh  |            | 9           |
|              |             |             |            |             |
| Ad           | Senegal     | Cambodia    |            |             |
| ministration |             |             |            |             |
|              | Malawi      | Kenya       |            |             |
|              |             |             |            |             |
|              | Ukraine     | Uganda      |            |             |
|              |             |             |            |             |
|              |             | Zambia      |            |             |
+--------------+-------------+-------------+------------+-------------+
| Educat       | Bangladesh  |             |            | 9           |
| ion/Training |             |             |            |             |
| of Service   | Cambodia    |             |            |             |
| Providers    |             |             |            |             |
|              | Egypt       |             |            |             |
|              |             |             |            |             |
|              | Kenya       |             |            |             |
|              |             |             |            |             |
|              | Malawi      |             |            |             |
|              |             |             |            |             |
|              | Senegal     |             |            |             |
|              |             |             |            |             |
|              | Uganda      |             |            |             |
|              |             |             |            |             |
|              | Ukraine     |             |            |             |
|              |             |             |            |             |
|              | Zambia      |             |            |             |
+--------------+-------------+-------------+------------+-------------+
| Integration  | Bangladesh  | Cambodia    | Senegal    | 9           |
| of HR and    |             |             |            |             |
| Health       | Egypt       | Kenya       |            |             |
| System       |             |             |            |             |
|              | Malawi      | Uganda      |            |             |
|              |             |             |            |             |
|              | Zambia      | Ukraine     |            |             |
+--------------+-------------+-------------+------------+-------------+

+----------------+------------+------------+------------+------------+
| Table 4: How   |            |            |            |            |
| would you rank |            |            |            |            |
| the importance |            |            |            |            |
| of the         |            |            |            |            |
| following      |            |            |            |            |
| service        |            |            |            |            |
| delivery HCD   |            |            |            |            |
| issues in your |            |            |            |            |
| country?       |            |            |            |            |
+----------------+------------+------------+------------+------------+
|                | High       | Medium     | Low        | Response   |
|                | Priority   | Priority   | Priority   | Total      |
+----------------+------------+------------+------------+------------+
| Staff          | Bangladesh | Cambodia   | Uganda     | 9          |
| Recruitment    |            |            |            |            |
|                | Malawi     | Egypt      | Ukraine    |            |
|                |            |            |            |            |
|                | Senegal    | Kenya      |            |            |
|                |            |            |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+
| Staff          | Cambodia   | Bangladesh | Ukraine    | 9          |
| Deployment     |            |            |            |            |
|                | Egypt      | Malawi     |            |            |
|                |            |            |            |            |
|                | Kenya      | Uganda     |            |            |
|                |            |            |            |            |
|                | Senegal    |            |            |            |
|                |            |            |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+
| Career         | Bangladesh | Egypt      |            | 9          |
| Development    | Cambodia   |            |            |            |
|                |            | Kenya      |            |            |
|                | Malawi     |            |            |            |
|                |            | Uganda     |            |            |
|                | Senegal    |            |            |            |
|                |            | Ukraine    |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+
| Staff          | Bangladesh | Kenya      | Uganda     | 9          |
| Retention      | Cambodia   |            |            |            |
|                |            |            | Ukraine    |            |
|                | Egypt      |            |            |            |
|                |            |            |            |            |
|                | Malawi     |            |            |            |
|                |            |            |            |            |
|                | Senegal    |            |            |            |
|                |            |            |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+
| Staff          | Bangladesh | Cambodia   |            | 9          |
| Appraisal      |            |            |            |            |
|                | Egypt      | Kenya      |            |            |
|                |            |            |            |            |
|                | Malawi     | Ukraine    |            |            |
|                |            |            |            |            |
|                | Senegal    |            |            |            |
|                |            |            |            |            |
|                | Uganda     |            |            |            |
|                |            |            |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+
| Time/Attend    | Bangladesh | Malawi     | Uganda     | 8          |
| Reporting      |            |            |            |            |
|                | Cambodia   |            | Ukraine    |            |
|                |            |            |            |            |
|                | Egypt      |            |            |            |
|                |            |            |            |            |
|                | Senegal    |            |            |            |
|                |            |            |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+
| Employee       | Cambodia   | Bangladesh |            | 8          |
| Incentives     |            |            |            |            |
|                | Malawi     | Egypt      |            |            |
|                |            |            |            |            |
|                | Senegal    | Ukraine    |            |            |
|                |            |            |            |            |
|                | Uganda     |            |            |            |
|                |            |            |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+
| Service        | Cambodia   | Bangladesh |            | 8          |
| Conditions     |            |            |            |            |
|                | Egypt      |            |            |            |
|                |            |            |            |            |
|                | Malawi     |            |            |            |
|                |            |            |            |            |
|                | Senegal    |            |            |            |
|                |            |            |            |            |
|                | Uganda     |            |            |            |
|                |            |            |            |            |
|                | Ukraine    |            |            |            |
|                |            |            |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+
| Terms of       | Cambodia   | Bangladesh |            | 8          |
| Employment     |            |            |            |            |
|                | Malawi     | Egypt      |            |            |
|                |            |            |            |            |
|                | Senegal    |            |            |            |
|                |            |            |            |            |
|                | Uganda     |            |            |            |
|                |            |            |            |            |
|                | Ukraine    |            |            |            |
|                |            |            |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+

+-----------------+------------+------------+------------+-----------+
| Pre-Service     | Bangladesh | Kenya      |            | 9         |
| Training        |            |            |            |           |
|                 | Cambodia   |            |            |           |
|                 |            |            |            |           |
|                 | Egypt      |            |            |           |
|                 |            |            |            |           |
|                 | Malawi     |            |            |           |
|                 |            |            |            |           |
|                 | Senegal    |            |            |           |
|                 |            |            |            |           |
|                 | Uganda     |            |            |           |
|                 |            |            |            |           |
|                 | Ukraine    |            |            |           |
|                 |            |            |            |           |
|                 | Zambia     |            |            |           |
+-----------------+------------+------------+------------+-----------+
| In-Service      | Bangladesh | Kenya      |            | 9         |
| Training        |            |            |            |           |
|                 | Cambodia   | Senegal    |            |           |
|                 |            |            |            |           |
|                 | Egypt      |            |            |           |
|                 |            |            |            |           |
|                 | Malawi     |            |            |           |
|                 |            |            |            |           |
|                 | Uganda     |            |            |           |
|                 |            |            |            |           |
|                 | Ukraine    |            |            |           |
|                 |            |            |            |           |
|                 | Zambia     |            |            |           |
+-----------------+------------+------------+------------+-----------+
| Certificatio    | Bangladesh | Malawi     |            | 9         |
| n/Accreditation |            |            |            |           |
|                 | Cambodia   | Zambia     |            |           |
|                 |            |            |            |           |
|                 | Egypt      |            |            |           |
|                 |            |            |            |           |
|                 | Kenya      |            |            |           |
|                 |            |            |            |           |
|                 | Senegal    |            |            |           |
|                 |            |            |            |           |
|                 | Uganda     |            |            |           |
|                 |            |            |            |           |
|                 | Ukraine    |            |            |           |
+-----------------+------------+------------+------------+-----------+
| Civil Service   | Cambodia   | Bangladesh | Egypt      | 9         |
| Reform          |            |            |            |           |
|                 | Kenya      | Malawi     |            |           |
|                 |            |            |            |           |
|                 | Uganda     | Senegal    |            |           |
|                 |            |            |            |           |
|                 | Zambia     | Ukraine    |            |           |
+-----------------+------------+------------+------------+-----------+
| Workload        | Bangladesh | Egypt      | Uganda     | 8         |
| Planning        |            |            |            |           |
|                 | Cambodia   | Senegal    |            |           |
|                 |            |            |            |           |
|                 | Malawi     | Ukraine    |            |           |
|                 |            |            |            |           |
|                 | Zambia     |            |            |           |
+-----------------+------------+------------+------------+-----------+
| Training HR     | Bangladesh | Egypt      | Senegal    | 8         |
| Specialists     |            |            |            |           |
|                 | Cambodia   | Malawi     | Ukraine    |           |
|                 |            |            |            |           |
|                 | Zambia     | Uganda     |            |           |
+-----------------+------------+------------+------------+-----------+

+----------------+------------+------------+------------+------------+
| Table 5: What  |            |            |            |            |
| is the         |            |            |            |            |
| likelihood     |            |            |            |            |
| (probability)  |            |            |            |            |
| that USAID     |            |            |            |            |
| resources and  |            |            |            |            |
| technical      |            |            |            |            |
| assistance     |            |            |            |            |
| could be       |            |            |            |            |
| effective in   |            |            |            |            |
| changing       |            |            |            |            |
| policies and   |            |            |            |            |
| practices in   |            |            |            |            |
| the following  |            |            |            |            |
| HCD areas      |            |            |            |            |
| given your     |            |            |            |            |
| host country   |            |            |            |            |
| political,     |            |            |            |            |
| regulatory,    |            |            |            |            |
| and legal      |            |            |            |            |
| environments?  |            |            |            |            |
+----------------+------------+------------+------------+------------+
|                | High       | Moderate   | Low        | Response   |
|                |            |            |            |            |
|                | P          | P          | P          | Total      |
|                | robability | robability | robability |            |
+----------------+------------+------------+------------+------------+
| Staff          | Malawi     | Cambodia   | Bangladesh | 9          |
| Recruitment    |            |            |            |            |
|                |            | Zambia     | Egypt      |            |
|                |            |            |            |            |
|                |            |            | Kenya      |            |
|                |            |            |            |            |
|                |            |            | Senegal    |            |
|                |            |            |            |            |
|                |            |            | Uganda     |            |
|                |            |            |            |            |
|                |            |            | Ukraine    |            |
+----------------+------------+------------+------------+------------+
| Staff          | Cambodia   | Egypt      | Bangladesh | 9          |
| Deployment     |            |            |            |            |
|                | Malawi     |            | Kenya      |            |
|                |            |            |            |            |
|                | Zambia     |            | Senegal    |            |
|                |            |            |            |            |
|                |            |            | Uganda     |            |
|                |            |            |            |            |
|                |            |            | Ukraine    |            |
+----------------+------------+------------+------------+------------+
| Career         | Bangladesh | Egypt      | Kenya      | 9          |
| Development    |            |            |            |            |
|                | Cambodia   | Senegal    | Uganda     |            |
|                |            |            |            |            |
|                | Malawi     | Ukraine    |            |            |
|                |            |            |            |            |
|                |            | Zambia     |            |            |
+----------------+------------+------------+------------+------------+
| Staff          | Zambia     | Cambodia   | Bangladesh | 9          |
| Retention      |            |            |            |            |
|                |            | Malawi     | Egypt      |            |
|                |            |            |            |            |
|                |            |            | Kenya      |            |
|                |            |            |            |            |
|                |            |            | Senegal    |            |
|                |            |            |            |            |
|                |            |            | Uganda     |            |
|                |            |            |            |            |
|                |            |            | Ukraine    |            |
+----------------+------------+------------+------------+------------+
| Staff          |            | Bangladesh | Cambodia   | 9          |
| Appraisal      |            |            |            |            |
|                |            | Egypt      | Kenya      |            |
|                |            |            |            |            |
|                |            | Malawi     | Senegal    |            |
|                |            |            |            |            |
|                |            | Ukraine    | Uganda     |            |
+----------------+------------+------------+------------+------------+
| Time/Attend    |            | Bangladesh | Egypt      | 9          |
| Reporting      |            |            |            |            |
|                |            | Cambodia   | Kenya      |            |
|                |            |            |            |            |
|                |            |            | Malawi     |            |
|                |            |            |            |            |
|                |            |            | Senegal    |            |
|                |            |            |            |            |
|                |            |            | Uganda     |            |
|                |            |            |            |            |
|                |            |            | Ukraine    |            |
|                |            |            |            |            |
|                |            |            | Zambia     |            |
+----------------+------------+------------+------------+------------+
| Employee       |            | Cambodia   | Bangladesh | 9          |
| Incentives     |            |            |            |            |
|                |            | Senegal    | Egypt      |            |
|                |            |            |            |            |
|                |            | Ukraine    | Kenya      |            |
|                |            |            |            |            |
|                |            |            | Malawi     |            |
|                |            |            |            |            |
|                |            |            | Uganda     |            |
|                |            |            |            |            |
|                |            |            | Zambia     |            |
+----------------+------------+------------+------------+------------+
| Service        | Malawi     | Bangladesh | Kenya      | 9          |
| Conditions     |            |            |            |            |
|                |            | Cambodia   | Senegal    |            |
|                |            |            |            |            |
|                |            | Egypt      | Uganda     |            |
|                |            |            |            |            |
|                |            | Ukraine    | Zambia     |            |
+----------------+------------+------------+------------+------------+
| Terms of       |            | Bangladesh | Cambodia   | 9          |
| Employment     |            |            |            |            |
|                |            | Malawi     | Egypt      |            |
|                |            |            |            |            |
|                |            | Ukraine    | Kenya      |            |
|                |            |            |            |            |
|                |            |            | Senegal    |            |
|                |            |            |            |            |
|                |            |            | Uganda     |            |
|                |            |            |            |            |
|                |            |            | Zambia     |            |
+----------------+------------+------------+------------+------------+
| Pre-Service    | Cambodia   | Bangladesh | Senegal    | 9          |
| Training       |            |            |            |            |
|                | Egypt      | Kenya      |            |            |
|                |            |            |            |            |
|                | Malawi     |            |            |            |
|                |            |            |            |            |
|                | Uganda     |            |            |            |
|                |            |            |            |            |
|                | Ukraine    |            |            |            |
|                |            |            |            |            |
|                | Zambia     |            |            |            |
+----------------+------------+------------+------------+------------+

+-----------------+------------+------------+------------+-----------+
| In-Service      | Cambodia   | Bangladesh |            | 9         |
| Training        |            |            |            |           |
|                 | Egypt      | Kenya      |            |           |
|                 |            |            |            |           |
|                 | Malawi     | Senegal    |            |           |
|                 |            |            |            |           |
|                 | Uganda     |            |            |           |
|                 |            |            |            |           |
|                 | Ukraine    |            |            |           |
|                 |            |            |            |           |
|                 | Zambia     |            |            |           |
+-----------------+------------+------------+------------+-----------+
| Certificatio    | Bangladesh | Egypt      |            | 9         |
| n/Accreditation |            |            |            |           |
|                 | Cambodia   | Kenya      |            |           |
|                 |            |            |            |           |
|                 | Ukraine    | Malawi     |            |           |
|                 |            |            |            |           |
|                 | Zambia     | Senegal    |            |           |
|                 |            |            |            |           |
|                 |            | Uganda     |            |           |
+-----------------+------------+------------+------------+-----------+
| Civil Service   |            | Bangladesh | Cambodia   | 9         |
| Reform          |            |            |            |           |
|                 |            | Malawi     | Egypt      |           |
|                 |            |            |            |           |
|                 |            | Ukraine    | Kenya      |           |
|                 |            |            |            |           |
|                 |            |            | Senegal    |           |
|                 |            |            |            |           |
|                 |            |            | Uganda     |           |
|                 |            |            |            |           |
|                 |            |            | Zambia     |           |
+-----------------+------------+------------+------------+-----------+
| Workload        | Bangladesh | Cambodia   | Kenya      | 9         |
| Planning        |            |            |            |           |
|                 |            | Egypt      | Senegal    |           |
|                 |            |            |            |           |
|                 |            | Malawi     | Ukraine    |           |
|                 |            |            |            |           |
|                 |            | Uganda     |            |           |
|                 |            |            |            |           |
|                 |            | Zambia     |            |           |
+-----------------+------------+------------+------------+-----------+
| Training HR     | Bangladesh | Egypt      | Kenya      | 9         |
| Specialists     |            |            |            |           |
|                 | Cambodia   |            | Malawi     |           |
|                 |            |            |            |           |
|                 | Uganda     |            | Senegal    |           |
|                 |            |            |            |           |
|                 | Zambia     |            | Ukraine    |           |
+-----------------+------------+------------+------------+-----------+

APPENDIX VII

Human Capacity Development Needs and Actionable Priorities Reported

by Cooperating Agencies

+-----------+---------+---------+--------+--------+--------+--------+
| Table 1:  |         |         |        |        |        |        |
| How would |         |         |        |        |        |        |
| you       |         |         |        |        |        |        |
| cha       |         |         |        |        |        |        |
| racterize |         |         |        |        |        |        |
| trends in |         |         |        |        |        |        |
| p         |         |         |        |        |        |        |
| er-capita |         |         |        |        |        |        |
| ava       |         |         |        |        |        |        |
| ilability |         |         |        |        |        |        |
| of health |         |         |        |        |        |        |
| service   |         |         |        |        |        |        |
| providers |         |         |        |        |        |        |
| in the    |         |         |        |        |        |        |
| countries |         |         |        |        |        |        |
| where     |         |         |        |        |        |        |
| your      |         |         |        |        |        |        |
| org       |         |         |        |        |        |        |
| anization |         |         |        |        |        |        |
| works     |         |         |        |        |        |        |
| over the  |         |         |        |        |        |        |
| past      |         |         |        |        |        |        |
| decade?   |         |         |        |        |        |        |
+-----------+---------+---------+--------+--------+--------+--------+
|           | Greatly | D       | Re     | Im     | G      | Re     |
|           | Deter   | eclined | mained | proved | reatly | sponse |
|           | iorated |         |        |        |        |        |
|           |         | S       | Same   |        | Im     | Total  |
|           |         | omewhat |        |        | proved |        |
+-----------+---------+---------+--------+--------+--------+--------+
| CA        |         |         |        |        |        |        |
|           |         |         |        |        |        |        |
| Repres    |         |         |        |        |        |        |
| entatives |         |         |        |        |        |        |
+-----------+---------+---------+--------+--------+--------+--------+
| Urban     | MSH     | Pat     | Basics | John   |        | 8      |
|           |         | hfinder | II     | Snow   |        |        |
|           |         |         |        |        |        |        |
|           |         | URC     |        | J      |        |        |
|           |         |         |        | HPIEGO |        |        |
|           |         |         |        |        |        |        |
|           |         |         |        | PHR+   |        |        |
|           |         |         |        |        |        |        |
|           |         |         |        | Prime  |        |        |
|           |         |         |        | II     |        |        |
+-----------+---------+---------+--------+--------+--------+--------+
| Rural     | MSH     | John    | Basics | PHR+   |        | 8      |
|           |         | Snow    | II     |        |        |        |
|           | Pat     |         |        |        |        |        |
|           | hfinder | URC     | J      |        |        |        |
|           |         |         | HPIEGO |        |        |        |
|           |         |         |        |        |        |        |
|           |         |         | Prime  |        |        |        |
|           |         |         | II     |        |        |        |
+-----------+---------+---------+--------+--------+--------+--------+
| National  | MSH     | Pat     | Basics | J      |        | 8      |
|           |         | hfinder | II     | HPIEGO |        |        |
|           |         |         |        |        |        |        |
|           |         | URC     | John   | PHR+   |        |        |
|           |         |         | Snow   |        |        |        |
|           |         |         |        | Prime  |        |        |
|           |         |         |        | II     |        |        |
+-----------+---------+---------+--------+--------+--------+--------+

+-----------+----------+-----------+-----------+----------+----------+
| Table 2:  |          |           |           |          |          |
| How would |          |           |           |          |          |
| you rank  |          |           |           |          |          |
| the       |          |           |           |          |          |
| i         |          |           |           |          |          |
| mportance |          |           |           |          |          |
| of the    |          |           |           |          |          |
| following |          |           |           |          |          |
| common    |          |           |           |          |          |
| HCD       |          |           |           |          |          |
| service   |          |           |           |          |          |
| provider  |          |           |           |          |          |
| i         |          |           |           |          |          |
| mbalances |          |           |           |          |          |
| in the    |          |           |           |          |          |
| countries |          |           |           |          |          |
| where     |          |           |           |          |          |
| your      |          |           |           |          |          |
| org       |          |           |           |          |          |
| anization |          |           |           |          |          |
| is        |          |           |           |          |          |
| working?  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
|           | Greatly  | M         | Low       | Not      | Response |
|           |          | oderately | I         |          |          |
|           | I        |           | mportance | I        | Total    |
|           | mportant | Important |           | mportant |          |
+-----------+----------+-----------+-----------+----------+----------+
| CA        |          |           |           |          |          |
|           |          |           |           |          |          |
| Repres    |          |           |           |          |          |
| entatives |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | Basics   | P         | Prime II  |          | 6        |
| New       | II       | athfinder |           |          |          |
| Entrants  |          |           |           |          |          |
| to Total  | MSH      | JHPIEGO   |           |          |          |
| Provider  |          |           |           |          |          |
| Stock Too | URC      |           |           |          |          |
| Low       |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | Basics   | P         | PHR+      |          | 7        |
| Sp        | II       | athfinder |           |          |          |
| ecialists |          |           | URC       |          |          |
| to        | JHPIEGO  | MSH       |           |          |          |
| Ge        |          |           |           |          |          |
| neralists |          | Prime II  |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | Basics   | MSH       | Prime II  |          | 7        |
|           | II       |           |           |          |          |
| Doctors   |          | PHR+      | URC       |          |          |
| to Nurses | JHPIEGO  |           |           |          |          |
| Too       |          |           |           |          |          |
|           | Pa       |           |           |          |          |
| High      | thfinder |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | JHPIEGO  | MSH       | Basics II |          | 6        |
| Nurses to |          |           |           |          |          |
| Auxiliary |          | URC       | P         |          |          |
| Nurse     |          |           | athfinder |          |          |
| /Midwives |          |           |           |          |          |
| Too High  |          |           | Prime II  |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio of  | Basics   | PHR+      |           |          | 7        |
| Urban to  | II       |           |           |          |          |
| Rural     |          | Prime II  |           |          |          |
| Providers | JHPIEGO  |           |           |          |          |
| Too High  |          | URC       |           |          |          |
|           | MSH      |           |           |          |          |
|           |          |           |           |          |          |
|           | Pa       |           |           |          |          |
|           | thfinder |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+
| Ratio     | JHPIEGO  | P         | MSH       | Basics   | 6        |
| Emigrant  |          | athfinder |           | II       |          |
| to        |          |           |           |          |          |
| Retained  |          | Prime II  |           | URC      |          |
| Providers |          |           |           |          |          |
| Too High  |          |           |           |          |          |
+-----------+----------+-----------+-----------+----------+----------+

+--------------+-------------+-------------+------------+-------------+
| Table 3:     |             |             |            |             |
| Which HCD    |             |             |            |             |
| components   |             |             |            |             |
| are being    |             |             |            |             |
| addressed in |             |             |            |             |
| your         |             |             |            |             |
| projects at  |             |             |            |             |
| the present  |             |             |            |             |
| time?        |             |             |            |             |
+--------------+-------------+-------------+------------+-------------+
|              | Yes         | No          | Don't Know | Response    |
|              |             |             |            | Total       |
+--------------+-------------+-------------+------------+-------------+
| CA           |             |             |            |             |
|              |             |             |            |             |
| Rep          |             |             |            |             |
| resentatives |             |             |            |             |
+--------------+-------------+-------------+------------+-------------+
| Supply       | JHPIEGO     | Basics II   | John Snow  | 7           |
| System       |             |             |            |             |
|              | PHR+        | MSH         |            |             |
| for Health   |             |             |            |             |
|              | URC         | Prime II    |            |             |
+--------------+-------------+-------------+------------+-------------+
| Performance  | JHPIEGO     | Basics II   |            | 7           |
|              |             |             |            |             |
| Management   | John Snow   | MSH         |            |             |
|              |             |             |            |             |
|              | Prime II    | PHR+        |            |             |
|              |             |             |            |             |
|              | URC         |             |            |             |
+--------------+-------------+-------------+------------+-------------+
| Personnel    | Prime II    | Basics II   | John Snow  | 7           |
|              |             |             |            |             |
| Ad           | URC         | JHPIEGO     |            |             |
| ministration |             |             |            |             |
|              |             | MSH         |            |             |
|              |             |             |            |             |
|              |             | PHR+        |            |             |
+--------------+-------------+-------------+------------+-------------+
| Educat       | JHPIEGO     | Basics II   |            | 7           |
| ion/Training |             |             |            |             |
| of Service   | John Snow   |             |            |             |
| Providers    |             |             |            |             |
|              | MSH         |             |            |             |
|              |             |             |            |             |
|              | PHR+        |             |            |             |
|              |             |             |            |             |
|              | Prime II    |             |            |             |
|              |             |             |            |             |
|              | URC         |             |            |             |
+--------------+-------------+-------------+------------+-------------+
| Integration  | JHPIEGO     | Basics II   | John Snow  | 7           |
| of HR and    |             |             |            |             |
| Health       | URC         | MSH         |            |             |
| System       |             |             |            |             |
|              |             | PHR+        |            |             |
|              |             |             |            |             |
|              |             | Prime II    |            |             |
+--------------+-------------+-------------+------------+-------------+

+-----------------+------------+------------+------------+------------+
| Table 4: How    |            |            |            |            |
| would you rank  |            |            |            |            |
| the importance  |            |            |            |            |
| of the          |            |            |            |            |
| following       |            |            |            |            |
| service         |            |            |            |            |
| delivery HCD    |            |            |            |            |
| issues in the   |            |            |            |            |
| countries where |            |            |            |            |
| your country    |            |            |            |            |
| works?          |            |            |            |            |
+-----------------+------------+------------+------------+------------+
|                 | High       | Medium     | Low        | Response   |
|                 | Priority   | Priority   | Priority   | Total      |
+-----------------+------------+------------+------------+------------+
| Staff           | JHPIEGO    | Basics II  | PHR+       | 8          |
| Recruitment     |            |            |            |            |
|                 | John Snow  | Pathfinder | URC        |            |
|                 |            |            |            |            |
|                 | MSH        | Prime II   |            |            |
+-----------------+------------+------------+------------+------------+
| Staff           | Basics II  | John Snow  |            | 8          |
| Deployment      |            |            |            |            |
|                 | JHPIEGO    | PHR+       |            |            |
|                 |            |            |            |            |
|                 | MSH        |            |            |            |
|                 |            |            |            |            |
|                 | Pathfinder |            |            |            |
|                 |            |            |            |            |
|                 | Prime II   |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Career          | Basics II  | John Snow  |            | 8          |
| Development     |            |            |            |            |
|                 | JHPIEGO    | Pathfinder |            |            |
|                 |            |            |            |            |
|                 | MSH        |            |            |            |
|                 |            |            |            |            |
|                 | PHR+       |            |            |            |
|                 |            |            |            |            |
|                 | Prime II   |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Staff Retention | JHPIEGO    | PHR+       |            | 8          |
|                 |            |            |            |            |
|                 | John Snow  | Basics II  |            |            |
|                 |            |            |            |            |
|                 | MSH        |            |            |            |
|                 |            |            |            |            |
|                 | Pathfinder |            |            |            |
|                 |            |            |            |            |
|                 | Prime II   |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Staff Appraisal | John Snow  | Basics II  | Pathfinder | 8          |
|                 |            |            |            |            |
|                 | MSH        | JHPIEGO    |            |            |
|                 |            |            |            |            |
|                 | PHR+       |            |            |            |
|                 |            |            |            |            |
|                 | Prime II   |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Time/Attend     | MSH        | JHPIEGO    | Basics II  | 8          |
| Reporting       |            |            |            |            |
|                 | PHR+       | John Snow  | Pathfinder |            |
|                 |            |            |            |            |
|                 | URC        | Prime II   |            |            |
+-----------------+------------+------------+------------+------------+
| Employee        | Basics II  | Pathfinder |            | 8          |
| Incentives      |            |            |            |            |
|                 | JHPIEGO    |            |            |            |
|                 |            |            |            |            |
|                 | John Snow  |            |            |            |
|                 |            |            |            |            |
|                 | MSH        |            |            |            |
|                 |            |            |            |            |
|                 | PHR+       |            |            |            |
|                 |            |            |            |            |
|                 | Prime II   |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Service         | Basics II  | John Snow  | Pathfinder | 8          |
| Conditions      |            |            |            |            |
|                 | JHPIEGO    | PHR+       |            |            |
|                 |            |            |            |            |
|                 | MSH        | Prime II   |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Terms of        | Basics II  | John Snow  |            | 8          |
| Employment      |            |            |            |            |
|                 | JHPIEGO    | Pathfinder |            |            |
|                 |            |            |            |            |
|                 | MSH        | PHR+       |            |            |
|                 |            |            |            |            |
|                 | URC        | Prime II   |            |            |
+-----------------+------------+------------+------------+------------+
| Pre-Service     | Basics II  | Prime II   |            | 8          |
| Training        |            |            |            |            |
|                 | JHPIEGO    |            |            |            |
|                 |            |            |            |            |
|                 | John Snow  |            |            |            |
|                 |            |            |            |            |
|                 | MSH        |            |            |            |
|                 |            |            |            |            |
|                 | Pathfinder |            |            |            |
|                 |            |            |            |            |
|                 | PHR+       |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+

+-----------------+------------+------------+------------+------------+
| In-Service      | Basics II  | Prime II   |            | 8          |
| Training        |            |            |            |            |
|                 | JHPIEGO    |            |            |            |
|                 |            |            |            |            |
|                 | John Snow  |            |            |            |
|                 |            |            |            |            |
|                 | MSH        |            |            |            |
|                 |            |            |            |            |
|                 | Pathfinder |            |            |            |
|                 |            |            |            |            |
|                 | PHR+       |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Certificatio    | JHPIEGO    | MSH        | Basics II  | 8          |
| n/Accreditation |            |            |            |            |
|                 | John Snow  | Prime II   |            |            |
|                 |            |            |            |            |
|                 | PHR+       | URC        |            |            |
+-----------------+------------+------------+------------+------------+
| Civil Service   | JHPIEGO    | John Snow  | Basics II  | 8          |
| Reform          |            |            |            |            |
|                 | MSH        | Prime II   |            |            |
|                 |            |            |            |            |
|                 | Pathfinder |            |            |            |
|                 |            |            |            |            |
|                 | PHR+       |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Workload        | JHPIEGO    | John Snow  | Basics II  | 8          |
| Planning        |            |            |            |            |
|                 | MSH        |            |            |            |
|                 |            |            |            |            |
|                 | Pathfinder |            |            |            |
|                 |            |            |            |            |
|                 | PHR+       |            |            |            |
|                 |            |            |            |            |
|                 | Prime II   |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Training HR     | John Snow  | JHPIEGO    | Basics II  | 8          |
| Specialists     |            |            |            |            |
|                 | MSH        | Pathfinder |            |            |
|                 |            |            |            |            |
|                 | PHR+       | Prime II   |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+

+-----------------+------------+------------+------------+------------+
| Table 5: What   |            |            |            |            |
| is the          |            |            |            |            |
| likelihood      |            |            |            |            |
| (probability)   |            |            |            |            |
| that USAID      |            |            |            |            |
| resources and   |            |            |            |            |
| technical       |            |            |            |            |
| assistance      |            |            |            |            |
| could be        |            |            |            |            |
| effective in    |            |            |            |            |
| changing        |            |            |            |            |
| policies and    |            |            |            |            |
| practices in    |            |            |            |            |
| the following   |            |            |            |            |
| HCD areas given |            |            |            |            |
| indigenous      |            |            |            |            |
| political,      |            |            |            |            |
| regulatory, and |            |            |            |            |
| legal           |            |            |            |            |
| environments?   |            |            |            |            |
+-----------------+------------+------------+------------+------------+
|                 | High       | Moderate   | Low        | Response   |
|                 |            |            |            |            |
|                 | P          | P          | P          | Total      |
|                 | robability | robability | robability |            |
+-----------------+------------+------------+------------+------------+
| Staff           | Prime II   | JHPIEGO    | Basics II  | 8          |
| Recruitment     |            |            |            |            |
|                 |            | John Snow  | Pathfinder |            |
|                 |            |            |            |            |
|                 |            | MSH        | PHR+       |            |
|                 |            |            |            |            |
|                 |            | URC        |            |            |
+-----------------+------------+------------+------------+------------+
| Staff           | JHPIEGO    | MSH        | Basics II  | 8          |
| Deployment      |            |            |            |            |
|                 | Prime II   | URC        | John Snow  |            |
|                 |            |            |            |            |
|                 |            |            | Pathfinder |            |
|                 |            |            |            |            |
|                 |            |            | PHR+       |            |
+-----------------+------------+------------+------------+------------+
| Career          | Prime II   | JHPIEGO    | Basics II  | 8          |
| Development     |            |            |            |            |
|                 |            | John Snow  | MSH        |            |
|                 |            |            |            |            |
|                 |            | MSH        |            |            |
|                 |            |            |            |            |
|                 |            | Pathfinder |            |            |
|                 |            |            |            |            |
|                 |            | PHR+       |            |            |
|                 |            |            |            |            |
|                 |            | Prime II   |            |            |
|                 |            |            |            |            |
|                 |            | URC        |            |            |
+-----------------+------------+------------+------------+------------+
| Staff Retention |            | JHPIEGO    | Basics II  | 8          |
|                 |            |            |            |            |
|                 |            | John Snow  |            |            |
|                 |            |            |            |            |
|                 |            | MSH        |            |            |
|                 |            |            |            |            |
|                 |            | Pathfinder |            |            |
|                 |            |            |            |            |
|                 |            | PHR+       |            |            |
|                 |            |            |            |            |
|                 |            | Prime II   |            |            |
|                 |            |            |            |            |
|                 |            | URC        |            |            |
+-----------------+------------+------------+------------+------------+
| Staff Appraisal | Pathfinder | JHPIEGO    | Basics II  | 8          |
|                 |            |            |            |            |
|                 | Prime II   | MSH        |            |            |
|                 |            |            |            |            |
|                 | URC        | PHR+       |            |            |
|                 |            |            |            |            |
|                 |            | John Snow  |            |            |
+-----------------+------------+------------+------------+------------+
| Time/Attend     | URC        | JHPIEGO    | Basics II  | 8          |
| Reporting       |            |            |            |            |
|                 |            | MSH        | John Snow  |            |
|                 |            |            |            |            |
|                 |            | PHR+       | Pathfinder |            |
|                 |            |            |            |            |
|                 |            | Prime II   |            |            |
+-----------------+------------+------------+------------+------------+
| Employee        | JHPIEGO    | John Snow  | Basics II  | 8          |
| Incentives      |            |            |            |            |
|                 |            | PHR+       | MSH        |            |
|                 |            |            |            |            |
|                 |            | Prime II   | Pathfinder |            |
|                 |            |            |            |            |
|                 |            | URC        |            |            |
+-----------------+------------+------------+------------+------------+
| Service         |            | JHPIEGO    | Basics II  | 8          |
| Conditions      |            |            |            |            |
|                 |            | PHR+       | John Snow  |            |
|                 |            |            |            |            |
|                 |            | Prime II   | MSH        |            |
|                 |            |            |            |            |
|                 |            |            | Pathfinder |            |
|                 |            |            |            |            |
|                 |            |            | URC        |            |
+-----------------+------------+------------+------------+------------+
| Terms of        |            | JHPIEGO    | Basics II  | 8          |
| Employment      |            |            |            |            |
|                 |            | John Snow  | MSH        |            |
|                 |            |            |            |            |
|                 |            | Prime II   | Pathfinder |            |
|                 |            |            |            |            |
|                 |            | URC        | PHR+       |            |
+-----------------+------------+------------+------------+------------+
| Pre-Service     | JHPIEGO    | PHR+       | Basics II  | 8          |
| Training        |            |            |            |            |
|                 | John Snow  | Prime II   |            |            |
|                 |            |            |            |            |
|                 | MSH        | URC        |            |            |
|                 |            |            |            |            |
|                 | Pathfinder |            |            |            |
+-----------------+------------+------------+------------+------------+
| In-Service      | JHPIEGO    | Pathfinder | Basics II  | 8          |
| Training        |            |            |            |            |
|                 | MSH        | PHR+       |            |            |
|                 |            |            |            |            |
|                 | John Snow  | Prime II   |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Certificatio    | JHPIEGO    |            | Basics II  | 8          |
| n/Accreditation |            |            |            |            |
|                 | John Snow  |            | MSH        |            |
|                 |            |            |            |            |
|                 | Pathfinder |            |            |            |
|                 |            |            |            |            |
|                 | PHR+       |            |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+
| Civil Service   |            | JHPIEGO    | Basics II  | 8          |
| Reform          |            |            |            |            |
|                 |            | John Snow  | MSH        |            |
|                 |            |            |            |            |
|                 |            | Prime II   | Pathfinder |            |
|                 |            |            |            |            |
|                 |            | URC        | PHR+       |            |
+-----------------+------------+------------+------------+------------+
| Workload        | Prime II   | MSH        | Basics II  | 8          |
| Planning        |            |            |            |            |
|                 | JHPIEGO    | Pathfinder |            |            |
|                 |            |            |            |            |
|                 | John Snow  | PHR+       |            |            |
|                 |            |            |            |            |
|                 |            | URC        |            |            |
+-----------------+------------+------------+------------+------------+
| Training HR     | JHPIEGO    | Pathfinder | Basics II  | 8          |
| Specialists     |            |            |            |            |
|                 | John Snow  | PHR+       |            |            |
|                 |            |            |            |            |
|                 | MSH        | Prime II   |            |            |
|                 |            |            |            |            |
|                 | URC        |            |            |            |
+-----------------+------------+------------+------------+------------+

APPENDIX VIII

Documents Consulted

Adams, Orville et al. 2002. "Human, physical, and intellectual resource
generation: proposals for monitoring". In Christopher Murray and David
Evans, *Health Systems Performance Assessment: Debates, Methods, and
Empiricism*. (Geneva: World Health Organization).

Berman, Peter. 2003. "Health sector reform in developing countries: now
more than ever". (Washington, DC: World Bank Web Site,
[www.worldbank.org/hnp/hsd/](http://www.worldbank.org/hnp/hsd/Viewpoint_ BermanJan03.asp)).

Biscoe, G. 2000. "Human resources: the political and policy context".
*Human Resources for Health Development Journal* 4(3).

Bolger, Joe. 2000. *Capacity Development: Why, What and How*. (Ottawa:
Policy Branch, CIDA).

Buchan, James and Mario R. Dal Poz. 2002. "Skill mix in the health care
workforce: reviewing the evidence." *Bulletin of the World Health
Organization*, 80(7).

Centers for Disease Control. 2003. *Public Health Systems Development*.
CDC Division of International Health. (Atlanta: CDC Web Site
www.cdc.gov.epo/dih/systems).

Family Health International. 2002. *Human Capacity Development for an
Effective Response to HIV/AIDS -- The Community Response: Addis Ababa,
Ethiopia*. (Addis Ababa, Ethiopia: Addis Ababa AIDS Council
Secretariat).

Family Health International. 2003. *Capacity Development in HIV
Programming*. (Durham, North Carolina: FHI Web Site,
[www.fhi.org/en/HIVAIDS/](http://www.fhi.org/en/HIVAIDS/Factsheets/capacdev.htm)FactSheets).

Green, Andrew. 1999. *Planning Human Resources: An Introduction to
Health Planning in Developing Countries, Second Edition.* (Oxford,
England: Oxford University Press).

Health Workforce Development Project: Highlights -- Detailed Activity
Description. No Date. (PowerPoint Presentation).

Heiby, James. 2003. "Human resources in health: talking points." USAID
Internal Memorandum.

Kolehmainen-Aitken, R. 1998. "Decentralization and human resources:
implications and impacts". *Human Resources Development Journal*, 2(1).

Lauro, Don. 1998. *Leadership Development and the Packard Population
Program: A Report to the David and Lucile Packard Foundation*. (Los
Altos: Packard Foundation).

Management Sciences for Health. 2003. "Human capacity development
inquiry". Developed by Management Sciences and Leadership Development
Program (M&L), (Draft memorandum).

Management Sciences for Health. 2003(b). *Report: Human Capacity
Development Workshop for an Effective Response to HIV/AIDS in Malawi,
March 27-28, 2003.* (Boston: Management Sciences for Health).

Martineau, Tim and J. Martinez. 1997. *Human Resources in the Health
Sector: Guidelines for Appraisal and Strategic Development*. (Brussels:
European Commission).

Martinez, Javier and T. Martineau. 1998. "Rethinking human resources: an
agenda for the millennium." *Health Policy and Planning*, 13(4).

Measure Evaluation. 2000. *Measuring Capacity Building in health and
Population Programs: Summary of Meeting held by Measure Evaluation,
November 16-17, 1999, Arlington, Virginia*. (Chapel Hill, North
Carolina: Carolina Population Center and the University of North
Carolina at Chapel Hill).

Milen, Anneli. 2001. *What do we know about Capacity Building? An
Overview of Existing Knowledge and Good Practice*. (Geneva: World Health
Organization).

Morgan, Peter. 1998. *Capacity and Capacity Development: Some
Strategies: Note Prepared for the Political and Social Policies
Division, Policy Branch, CIDA.* (Ottawa: Policy Branch, CIDA).

Necochea, Edgar, Kama Garrison, and Wendy Voet. 2003. *Human Resources
in Healthcare: A JHPIEGO Strategy Paper*. Draft Report. (Baltimore:
JHPIEGO).

Pan American Health Organization. 1998. *Human Resources: A Critical
factor in Health Sector Reform: Report of a Meeting in San Jose, Costa
Rica, 3-5 December, 1997.* (Washington, DC: PAHO).

Picazo, Oscar, J. Huddart, and S. Duale. 2003. *The Health Sector Human
Resource Crisis in Africa: An Issues Paper*. (Washington, DC: USAID,
Bureau for Africa, Office of Sustainable Development, AED, and the SARA
Project).

Prime II. 2003. *Strategy for Family Planning Program Recovery in
Nigeria*. (Chapel Hill, N.C.: Prime II Web Site,
[www.prime2.org](http://www.prime2.org/)).

Rohde, Jon and J. Wyon. 2003. *Community-Based Health Care: Lessons from
Bangladesh to Boston*. (Boston, Massachusetts: MSH).

Ross, John and John Stover. 2003. *Trends and Issues Affecting Service
delivery over the Next Decade*. Prepared for the Service Delivery
Improvement Division, Office of Population and Reproductive Health,
USAID. (Washington, DC: The Policy Project).

Schofeld, Kenneth G. 2002. *An Assessment of Alternative Procurement
Mechanisms*. Prepared for the Services Delivery Improvement Division,
Office of Population and Reproductive Health, Bureau for Global Health.
(Washington, DC: Poptech Project).

Standing, Hilary. 2001. "Gender -- a missing dimension in human resource
policy and planning for health reforms". *Human Resources Development
Journal*. 4(1).

Tawfik, L. and S. Kinota. 2001. *The Impact of HIV/AIDS on the Health
Sector in Sub-Saharan Africa: The Issue of Human Resources*.
(Washington, DC: USAID/SARA Project, Academy for Educational
Development).

Thollaug, Susan and Maria Mamlouk. 2002. "Use of bilateral mechanism for
PHN Programming in the Field: How Much and Why". (USAID Draft Report).

USAID. 2001. "Note on USAID initiative to strengthen human capacity to
lead, manage and implement HIV/AIDS and infectious disease (ID)
programs." (Internal memorandum).

USAID. 2001. "Human capacity development initiative -- draft global
workplan." (Internal memorandum).

USAID. 2002. *The Impact of HIV/AIDS on Health Systems in Sub-Saharan
Africa with Special Reference to the Issue of Human Resources*.
(Washington, DC: Bureau for Africa, Office of Sustainable Development).

USAID. 2003(a). IWG Working Group Session: human capacity development
(HCD. (USAID Internal Memorandum).

USAID. 2003(b). "HCD Task Force Meeting, June 16, 2003: summary of major
points from the meeting." (USAID Internal Memorandum).

USAID/Egypt. 2003. "Health workforce development (HWD)." (Internal
memorandum).

USAID, UNAIDS, and World Bank Institute. 2003. *Human Capacity
Development for an Effective Response to HIV/AIDS: Adapted by Management
Sciences for Health,* Powerpoint Presentation.

UNAIDS. 2003(a). *Best Practices Collection*. (Geneva: UNAIDS Web Site).

UNAIDS. 2003(b). *Implementation of the Declaration of Commitment on
HIV/AIDS: Core Indicators*. (Geneva, Switzerland: UNAIDS Web Site).

United States Department of Health and Human Services. 2003. Law and
Policy: Capacity Development -- HIV/AIDS Bureau. (Washington, DC: HHS
Web Site,
[www.hab.hrsa.gov/law/dssletter8.htm](http://www.hab.hrsa.gov/law/dssletter8.htm)).

University Research Corporation. 2003. *Zambia AIDS Workforce Study:
Draft Report of Findings.* (Washington, DC: QAP/Initiatives Inc.,
PowerPoint Presentation).

Waters, Hugh. 1995. *Regional Initiatives for Capacity Building in the
Health Sector*. (Washington, DC: Academy for Educational Development).

World Health Organization. 2001. *World Health Report 2000. Chapter 4:
What Resources are Needed*. (Geneva: WHO).

World Health Organization. 2001(b). *Workshop on Global Health Workforce
Strategy, Annecy, France, 9-12 December, 2000.* (Geneva: WHO).

World Health Organization. 2002a. *Human Resources for Health:
Developing Policy Options for Change -- Discussion Paper.* (Geneva:
WHO).

World Health Organization. 2002b. *Technical Consultation on Imbalance
in the Health* *Workforce*. (Geneva: Department of Health Services
Provision).

World Health Organization. 2003. *WHO Estimates of Health Personnel:
Physicans, Nurses, Midwives, Dentists, and Pharmacists (around 1998).*
(Geneva: WHO Web Site).

[^1]: For further elaboration of the organizational scheme presented in
    Table 1 see Martinez and Martineau, (1998), "Rethinking human
    resources: an agenda for the millennium", *Health Policy and
    Planning*, 13(4).

[^2]: [The Health Sector Human Resource Crisis in Africa: An Issues
    Paper]{.underline}, USAID February 2003, pg. 3

[^3]: IBID, pg. 6

[^4]: IBID, pg. 12