pepfar hrh strategy.pdf

PEPFAR Human Resources for Health Strategy

PEPFAR 3.0

February, 2015

PEPFAR HRH Strategy Page 2

Need for PEPFAR Human Resources for Health Strategy

PEPFAR is pivoting the scale-up of resources and services towards health service delivery sites with moderate and high yield of patients, communities that link patients to those sites, and geographic areas with high burden of HIV. Meeting demand in those settings requires an adequate supply and appropriate skills mix of HRH available to provide quality HIV services along the continuum of care.

Between 2009 and 2014, PEPFAR strengthened countries’ health systems to address Human Resources for Health (HRH) bottlenecks to service delivery broadly, and HIV services in particular (see Appendix 1 for summary of achievements). However, PEPFAR’s current pivot requires a recasting of its HRH investment approach to more directly support HIV services and populations where the highest impact gains towards an AIDS-free generation (AFG) will be felt.

HRH Strategy Goal and Objectives

Goal

To ensure that PEPFAR investments in HRH directly support the program’s overall pivot, the overarching goal of PEPFAR’s HRH Strategy is to:

Ensure adequate supply and quality of human resources for health to expand HIV/AIDS services in PEPFAR-supported moderate- and high-volume sites and/or high HIV-burden areas

Objectives

To support this goal, PEPFAR’s HRH investments will focus on five interrelated objectives that directly support PEPFAR re-alignment and achieving an AIDS-free generation:

Figure 1. PEPFAR HRH Objectives

These five objectives will be supported through both Headquarters Operational Plan (HOP)-funded activities and Country Operational Plan (COP)-funded activities.

Assess HRH Capacity needs

Develop site-level 'Supply' Strategies

Improve site-level recruitment, deployment and retention

Establish sustainable financing of HRH

Improve site-level HRH performance

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Objective 1: Assess HRH capacity needs to deliver HIV/AIDS services (prevention, care, and treatment) impacting PEPFAR-supported moderate- and high-volume sites and/or high HIV-burden areas

Problem Statement: Facility-and/or community-level HRH data in most PEPFAR countries are not well-enough developed to inform programmatic decisions. A continuous assessment of HRH capacity (supply), HIV services needs (demand), and associated HRH costs within both 1) PEPFAR-supported moderate- and high-volume sites and 2) the geographic areas that link high-volume sites to communities is a foundational element of any country-level HRH strategy.

Overall approach: PEPFAR country teams will carry out an annual analysis of HRH capacity needs at high-volume sites. Analyses will address a common set of key questions with data collected through existing data sources (PEPFAR or external) and/or additional assessments/studies as necessary.

Interventions Annual analysis of HRH capacity needs should address, inter alia, the following questions:

a) How many HRH are needed to support achievement of PEPFAR prevention, care and treatment targets at high-volume (i.e., moderate- and high-yield sites) and in high-burden geographic areas under existing HRH scopes of work/models of service delivery? Specifically, what is the number needed:

i) at moderate- and high-yield sites?

ii) at the community-level in high HIV disease burden areas?

iii) at other levels of the health systems (e.g., reference labs)?

b) Is there evidence that alternative HRH skills mix/models of service delivery could improve HRH efficiencies/productivity and reduce the HRH resource needs to support achievement of PEPFAR prevention, care and treatment targets at high-volume clinical sites and/or in high HIV-burden areas?

c) How will projected needs for HIV services in high-burden areas affect the required HRH stock and skills mix in the next 3 years?

d) What are the costs associated with a), b), and c), above?

e) How do HRH capacities (e.g., competencies, production potential, provider confidence) constrain demand for HIV services and/or scale up of HIV services in moderate- and high-volume sites and/or high HIV-burden areas?

f) What options exist to improve HRH performance to enhance quality of services? (e.g., motivation, HRH-focused quality improvement (QI))?

Objective 1 monitoring framework:

Operating Units (OUs): All PEPFAR countries with HRH investments submit results of HRH analyses as part of COP

HRH Technical Working Group (TWG):

i) Package of site HRH assessment tools/analysis plan distributed to field (by COP15)

ii) Ongoing TA/meta-analyses of OU-level HRH assessment and analyses

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Objective 2: Support adequate supply and appropriate skills mix of health workers to deliver HIV/AIDS services at PEPFAR-supported moderate- and high-volume program sites and/or high HIV-burden areas

Problem Statement: An insufficient number of health care workers with the right skills and ability to deliver HIV services in high HIV-burden areas/moderate- and high-volume program sites persists in many PEPFAR countries.

Overall Approach:

Develop a supply-side strategy to saturate moderate- and high-volume program sites and/or high HIV-burden areas with HRH, including: strengthening the capacity of pre-service training institutions for health care cadres involved in the HIV continuum of response at all levels in moderate- and high-volume sites and/or high HIV-burden areas; increasing availability of community health workers skilled in HIV, and working to improve community-facility linkage related to HIV services; and reducing constraints on existing HRH to deliver and/or scale up HIV services (e.g., absence of task sharing policies; restrictive scopes of practice).

Interventions:

a) Improve production capacities of pre-service education institutions by:

i) Increasing throughput of priority HRH cadres to provide HIV services in PEPFAR-supported moderate- and high-volume sites and/or high HIV-burden areas (e.g., through faculty development, curriculum development, infrastructure improvements, etc.)

ii) improving models of learning, such as through: adoption of updated and innovative HIV learning curriculum that addresses the needs of all HIV-affected patients, such as reducing stigma and discrimination; practices to support the rapid dissemination of quality HIV/AIDS training and training modalities in educational and moderate- and high-volume program sites and/or high HIV-burden areas community-based learning; and inter-disciplinary teams.

b) Support models of standardized training to produce community health workers skilled in HIV.

c) Expand the supply of existing health workers that can provide HIV services, including by developing national task-sharing policies and expanding scopes of practice.

Objective 2 monitoring framework (AFG outputs/outcomes):

Pre-service: Monitoring, Evaluation, and Reporting (MER) Level 1 Indicator (HRH_PRE): Number of health workers produced through pre-service education

Above-Site/Supportive Function Core Essential Elements (CEEs): Pre-Service Training

Facility level: SIMS “Staffing” CEE should improve toward green

Annual stock taking of progress on selected task sharing policies (e.g., for Nurse Initiated and Managed ART; initiation and management of HIV-positive pediatric patients; testing and counseling)

Objective 3: Establish recruitment, deployment, and retention strategies to ensure a consistent and sustainable supply of trained health workers at moderate- and high-volume sites and/or high HIV-burden areas.

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Problem Statement: With HIV care provider vacancy rates as high as 50-79% in many PEPFAR countries, scaling up HIV treatment for priority populations requires addressing root of the lack of health worker staffing and retention at moderate- and high-volume sites and/or high HIV-burden areas.

Overall Approach: Strengthen in-country human resource management systems to improve recruitment, deployment and retention of HIV/AIDS health workers at moderate- and high-volume sites and/or high HIV-burden areas.

Interventions:

Strengthen human resource information systems and health workforce registries and use available HRH data to improve HRH planning, management, and retention to health workers at moderate and high -volume sites and/or high HIV burden areas.

Strengthen linkages between HRH production and recruitment and deployment, ensuring that PEPFAR-supported pre-service education graduates are recruited and deployed to moderate- and high-volume sites and/or high HIV-burden areas (e.g. bonding, national allocation optimization tools)

Conduct assessments or desk reviews to understand the above-site barriers to health worker deployment and retention and link to site-level data

Assess retention schemes at the site level to determine how PEPFAR can strengthen these at moderate- and high-volume sites and/or high HIV-burden areas

Objective 3 monitoring framework (AFG outputs/outcomes):

MER Health Resource Information System (HRIS) Assessment Framework Indicator reflecting functionality and use of the HRIS should improve over time SIMS “staffing” CEE reflecting health workforce density at site level should improve toward green Sustainability Index factor on HR data collection and use should improve

Objective 4: Establish sustainable financing for health workers, which ensures adequate local financing for health workers that provide HIV/AIDS services at moderate- and high-volume sites and/or high HIV-burden areas and sustained capacity for sites where PEPFAR salary support has been transitioned.

Problem Statement: PEPFAR’s current support for over 130,000 health worker salaries across PEPFAR sites has heavily impacted countries’ ability to ultimately recruit and finance its HIV workforce and to realize sustainability of quality HIV service delivery. For increased HIV epidemic control, increased host country financing is needed for sustaining HRH capacity from PEPFAR transitioned sites.

Overall Approach: Develop country-level strategies for: realignment of cadres not recognized by the Ministry of Health (MOH) and supporting their integration into national health systems; aligning salary support with government salary packages; and working with host country institutions to plan, employ, and retain these health workers over time in collaboration with resource mobilization efforts.

Interventions:

Inventory of PEPFAR salary support (clinical, managerial/administrative, and community-based workers) that includes basic information on compensation packages, site location, and equivalent government cadre compensation package.

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Alignment of cadres not recognized by MOH and supporting their integration into the health system or identify a plan for integrating their roles into existing government recognized cadres

Alignment of PEPFAR salary support with government compensation packages

Continued engagement with ministries to plan for employment and ensure retention of PEPFAR-supported health workers in national systems (e.g., capacity for human resource management, performance management and health worker support).

Monitoring progress and impact of PEPFAR health worker transition to ensure health workers are retained and quality of HIV/AIDS services is not diminished after transition

Collaboration with domestic resource mobilization efforts for increased financing for HRH

Objective 4 monitoring framework (AFG outputs/outcomes):

Expenditure Analysis (EA) data on site-level expenditure on health worker salaries should diminish over time

COP health worker salary support table should show Full-Time Equivalents (FTEs) diminishing over time

PEPFAR Sustainability Index HRH element should improve

Objective 5: Improve health worker performance at moderate- and high-volume sites and/or high HIV-burden areas for service quality

Problem Statement: While task shifting to non-physician clinicians has enabled the scale-up of HIV/AIDS services across PEPFAR countries, quality of services remains a critical concern. This is due to many factors, including weak regulation of professional practice in HIV/AIDSi, fragmented clinical mentorship models, underdeveloped national training systems, and weak community-facility cadre relationships impacting functioning of linkages and referral systems related to HIV servicesiiiii. Sustainability is especially weak in this area.

Overall Approach: Assess the specific capacity needs of clinic teams providing HIV/AIDS services at high-HIV-burden areas/high-volume sites and design a country-specific strategy for supporting high quality performance of health/ community workers at these sites, which can be sustained locally.

Quality systems should enable countries to flexibly adapt performance standards, training, and mentorship to stay abreast with the continuously changing global and national service delivery guidelines.

Interventions:

a) In-service training (IST) systems to cover specific capacity gaps in high burden/ high volume sites (e.g. national IST framework and strategyivv; national continuing professional development program (CPD)vi; national/regional training centers), which can be sustained locally.

b) Clinical mentorship and/or supportive supervision systems for facility-based cadres delivering HIV services at high-HIV-burden areas/high-volume sites, which can be sustained locally.viiviiiix

c) Strengthened oversight and support systems (e.g. referral procedures/tools, supervision, training, incentives) for strengthening performance of community-based cadres delivering HIV services in high-HIV-burden areas/high-volume sites, which can be sustained locally and that improve community-facility linkages related to HIV services. xxixii

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d) Conduct performance assessment and management at high-HIV-burden areas/high-volume sites, including formulation of position descriptions, performance appraisal, and improvement plans.xiii

e) Ensure a quality improvement approach is functional at all high-HIV-burden areas/high-volume sites and increase utilization of QI methods at the community level

f) Ensure basic Quality Assurance (QA) mechanisms (e.g., Continuing Professional Development (CPD), re-licensure, Standard Operating Procedures (SOPs)) in place at national level for priority cadres to regulate health worker practice of HIV/AIDS services.

Objective 5 monitoring framework (AFG outputs/outcomes):

a) IST: EA data should show PEPFAR expenditures on IST diminishing over time

b) Clinical mentorship: SIMS CEE “supportive supervision in last X months” should progress

c) Performance assessment: SIMS CEE “performance support” should progress toward green

d) Community-Based Cadre Support and Referrals/Linkages: SIMS CEEs should progress toward green

e) QA: ARC Dashboard (RFF) should progress toward green on each regulatory function

Strategy implementation

PEPFAR expenditures on HRH cut across all technical areas and implicate the vast majority of Implementing Mechanisms. While some activities to support Strategy implementation will likely be programmed as stand-alone “HRH” activities (e.g., capacity building of HRIS), others may relate to core activities within other technical areas and Implementing Mechanisms (e.g., clinical mentorship for health/community workers). Implementing the HRH Strategy will therefore require coordination and/or actions to be taken both across all technical areas and at the OU and HQ levels. Specifically:

Within OUs: OUs are expected to convene a process by which to implement the Strategy (i.e., implement and monitor the five Objectives) that includes representatives from all relevant technical areas. Development, implementation and monitoring of the Strategy should not be de-linked from other PEPFAR business processes, including prioritization of core and near core activities/programmatic planning, monitoring of programs, etc.

At HQ: In consultation with the Office of Sustainability and Development, the HRH TWG will provide technical support to OUs and lead coordination of Strategy implementation. A process for coordinating with other TWGs will be formulated as part of the Strategy roll-out.

i McCarthy, CF et al. Nursing and midwifery regulation and HIV scale-up: establishing a baseline in east, central and southern Africa. Journal of the International AIDS Society. 2013, 16:18051.

ii Uwimana, J. et al. 2012. Engagement of Non-Government Organizations and Community Care Workers in

Collaborative TB/HIV Activities Including Prevention of Mother to Child Transmission in South Africa: Opportunities and Challenges. BMC Health Services Research. 12(233).

iii Lees, S. et al. 2010. Understanding the Linkages between Informal and Formal Care for People Living with HIV in sub-Saharan Africa. Global Public Health. 7(10).

iv

The PEPFAR IST Improvement Framework can be found at:

https://www.usaidassist.org/sites/assist/files/inservicetraining_july2013.11x17spreads.pdf.

v The PEPFAR Training Evaluation Framework can be found at: http://www.go2itech.org/resources/TEFT.

vi CPD case studies and progress in the Africa region can be found at: African Health Profession Collaborative for Nurses and

Midwives: AJM Supplement. African Journal of Midwifery and Women’s Health. April- June, 2014, Vol 8, No 2 (Supplement).

https://www.usaidassist.org/sites/assist/files/inservicetraining_july2013.11x17spreads.pdf http://www.go2itech.org/resources/TEFT

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Also, a CPD Toolkit for Nurses and Midwives can be found at:

http://africanregulatorycollaborative.com/Documents/ARCCPDToolkitApril2014000.pdf.

vii

A clinical mentorship toolkit can be found at: http://www.go2itech.org/resources/toolkits. A fact sheet on clinical mentorship can be found at: http://www.go2itech.org/what-we-do/health-workforce-development/clinical-mentoring.

viii

Arora, Sanjeev et al. Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers. New England Journal of Medicine.

ix Bradley, E. Hospital quality improvement in Ethiopia: a partnership-mentoring model. Int J Qual Health Care. 2008 Dec.;

20(6):392-9.

x Naimoli et al. Community and Formal Health System Support for Enhanced CHW Performance. USAID: 2012.

xi Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide for Program

Managers and Policy Makers. USAID: MCHIP. 2013.

xii Naimoli JF, Frymus DE, Wuliji T, et al. A Community Health Worker "logic model": towards a theory of enhanced performance in low- and middle-income countries. Hum Resour Health 2014; 12(1):56.

xiii

A fact sheet on health worker performance improvement can be found at:

https://www.usaidassist.org/sites/assist/files/improving_health_worker_performance_feb2014.pdf.

http://africanregulatorycollaborative.com/Documents/ARCCPDToolkitApril2014_000.pdf http://www.go2itech.org/resources/toolkits http://www.go2itech.org/what-we-do/health-workforce-development/clinical-mentoring http://www.usaid.gov/sites/default/files/documents/1864/CHW-Evidence-Summit-Final-Report.pdf http://www.usaid.gov/sites/default/files/documents/1864/CHW-Evidence-Summit-Final-Report.pdf http://www.usaid.gov/sites/default/files/documents/1864/CHW-Evidence-Summit-Final-Report.pdf http://www.usaid.gov/sites/default/files/documents/1864/CHW-Evidence-Summit-Final-Report.pdf http://www.usaid.gov/sites/default/files/documents/1864/CHW-Evidence-Summit-Final-Report.pdf http://www.mchip.net/sites/default/files/mchipfiles/MCHIP_CHW%20Ref%20Guide.pdf http://www.mchip.net/sites/default/files/mchipfiles/MCHIP_CHW%20Ref%20Guide.pdf http://www.mchip.net/sites/default/files/mchipfiles/MCHIP_CHW%20Ref%20Guide.pdf http://www.unboundmedicine.com/medline/citation/25278012/A_Community_Health_Worker_%22logic_model%22:_towards_a_theory_of_enhanced_performance_in_low__and_middle_income_countries_ http://www.unboundmedicine.com/medline/citation/25278012/A_Community_Health_Worker_%22logic_model%22:_towards_a_theory_of_enhanced_performance_in_low__and_middle_income_countries_ https://www.usaidassist.org/resources/improving-health-worker-performance https://www.usaidassist.org/sites/assist/files/improving_health_worker_performance_feb2014.pdf

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Appendix 1 – Summary of PEPFAR HRH achievements (2009-2014)

PEPFAR’s current Human Resources for Health (HRH) investments at the country and headquarters level focus on six priorities: (1) HRH planning and management; (2) pre-service education; (3) coordinated systems for in-service training; (4) innovative service delivery models (e.g., task shifting and utilization of quality improvement methodologies); (5) recruitment and retention; and (6) regulation (quality assurance) and policy. These priorities were identified as critical to establishing sustainable health workforce development systems in country, and were based on WHO and Global Health Workforce

Alliance frameworks for HRH development. The priorities also reflect an evolution from the first phase of PEPFAR – which emphasized rapid capacitation of health workers through scale up of HIV in-service training – to the second phase of PEPFAR – which had a Congressional mandate for health systems strengthening (HSS) and target of training and retaining 140,000 new health professionals. Over this time period, PEPFAR has served as one of the largest bilateral donors in HRH.

As the recent PEPFAR – USAID report to Congress demonstrates. PEPFAR investments in these HRH priorities have addressed HRH bottlenecks to scaling up HIV services. Notable impacts include:

Production of over 140,000 new health professionals (e.g. doctors, nurses, midwives, laboratorians) and training of over 600,000 community health and paraprofessionals involved in the delivery of HIV services, through capacitation of pre- and in-service institutions in over 23

PEPFAR countries.

Development of Human Resources Information Systems (HRIS) critical to workforce planning in

17 sub-Saharan Africa countries, leading directly to MOH recruitment of nearly 20,000 health professionals in Kenya and Uganda alone;

Advancing task-shifting policy, training, and/or mentorship for myriad HIV services, including

Nurse-Initiated and Managed ART (NIMART) in over 11 countries in east and southern Africa;

Facilitating the transition of thousands of PEPFAR salaries to host country financing in Namibia and South Africa alone and development of a PEPFAR HRH Transition Framework

Strengthening national regulation of nurses/midwives in 19 countries for quality assurance of

HIV service delivery, including 7 new national continuing medical education systems;

Establishing 19 national epidemiology training programs and an African network of trained and experienced epidemiologists;

Streamlining HIV In-Service Training portfolios and standardization of more efficient, effective, and sustainable training practices in 3 countries utilizing the globally endorsed PEPFAR IST

Improvement Framework; and

Introduction of use of quality improvement as an intervention to address factors impacting health worker performance in 24 countries.