Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening

BACKGROUND: Since the early 2000s there have been large increases in donor financing of human resources for health (HRH) yet few studies have examined their effects on health systems. OBJECTIVE: To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS Tuberculosis and Malaria (Global Fund) the largest investor in HRH outside national governments. METHODS: We used mixed research methodology to analyse budget allocations and expenditures for HRH including training for 138 countries receiving money from the Global Fund during funding rounds 1-7. From these aggregate figures we then identified 27 countries with the largest funding for human resources and training and examined all HRH-related performance indicators tracked in Global Fund grant reports. We used the results of these quantitative analyses to select six countries with substantial funding and varied characteristics-representing different regions and income levels for further in-depth study: Bangladesh (South and West Asia low income) Ethiopia (Eastern Africa low income) Honduras (Latin America lower-middle income) Indonesia (South and West Asia lower-middle income) Malawi (Southern Africa low income) and Ukraine (Eastern Europe and Central Asia upper-middle income). We used qualitative methods to gather information in each of the six countries through 159 interviews with key informants from 83 organizations. Using comparative case-study analysis we examined Global Funds interactions with other donors as well as its HRH support and co-ordination within national health systems. RESULTS: Around US$1.4 billion (23% of total US$5.1 billion) of grant funding was allocated to HRH by the 138 Global Fund recipient countries. In funding rounds 1-7 the six countries we studied in detail were awarded a total of 47 grants amounting to US$1.2 billion and HRH budgets of US$276 million of which approximately half were invested in disease-focused in-service and short-term training activities. Countries employed a variety of mechanisms including salary top-ups performance incentives extra compensation and contracting of workers for part-time work to pay health workers using Global Fund financing. Global Fund support for training and salary support was not co-ordinated with national strategic plans and there were major deficiencies in the data collected by the Global Fund to track HRH financing and to provide meaningful assessments of health system performance. CONCLUSION: The narrow disease focus and lack of co-ordination with national governments call into question the efficiency of funding and sustainability of Global Fund investments in HRH and their effectiveness in strengthening recipient countries health systems. The lessons that emerge from this analysis can be used by both the Global Fund and other donors to improve co-ordination of investments and the effectiveness of programmes in recipient countries. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine (c) The Author 2013; all rights reserved.