Amanda Banda on the White House Health Workforce Initiative
As the White House develops a new initiative to strengthen the global health workforce around the world, we spoke with Amanda Banda, a global health advocate at Wemos. We talked about what she thinks the Biden Administration needs to consider in order to help build a strong and sustainable health workforce in Africa.
What should the White House prioritize for this forthcoming initiative?
This initiative needs to be innovative, game changing, and catalytic at the same time. The US should use this initiative to innovate and alleviate the burdens facing the workforce especially in countries with the most severe shortages by the World Health Organization (WHO). The US should look at what exists now and build up from that because there are initiatives that are working and are promising, while of course working alongside the countries on what is needed in terms of priorities.
I think it needs to be a broad, holistic approach. We have seen innovations that cover specific things but are limited in impact and the more you plug one specific hole, the more it seems you open others. A typical example is that of governments training health workers in dire shortages: as soon as they graduate they leave and are hired by richer countries who are not necessarily investing in the training or any other HRH support in poorer countries who have the human resources, but insufficient fiscal space and infrastructure to recruit and retain them.
But a broad, holistic initiative that covers multiple facets of human resources for health is what works and is needed. It should be about preservice training, retention—especially in rural and hard to reach areas where the most population live, leadership, HRH development, gender, equity, management, and investing in salaries of not just community but also skilled health workers, in the short term of course. It is the whole system. If we are going to think about sustainability, it is time for us to invest in the whole system in a way that is easy for governments to take over in the longer term.
For this initiative to succeed the US must go beyond the ministries of health and build strong relationships with the ministries of finance and also consider engaging with other international financing institutions such as the World Bank and IMF for the fiscal policies that often limit government from exceeding certain wage bill ceilings, for debt management and cancellation. There is a need to look also at enabling and supporting countries on progressive taxation and tackling illicit financial flows if the US really wants a lasting solution. We know these are the elephants in the room and any program that will innovate and look at alternative financing for HRH in the long term will need to consider this. The US has the leverage and power to do so, and this fund could in part be used to innovate new lasting ways of looking at HRH. Lots of governments have robust plans for human resources for health, but there is a lack of funding to implement them.
How can the US help address retention and motivation?
The focus needs to be on retention and motivation of the workforce, especially in the rural areas where the most populations live. For this, it goes beyond just investing in the health sector overall—the initiative must consider how are we going to attract health care workers who want to live and work in the rural areas? It’s about infrastructure, which includes access to water, electricity, schools for children, and accessible roads to go to the nearest towns for the health workers, and provision of tools and resources for the health workers, both skilled and lay, and/or community health care workers to work with. Of course, the biggest motivation is a manageable workload and that can get resolved by increasing the numbers of health care workers to reduce attrition. To address retention and motivation, health workers often just want the right tools. If a health worker is delivering babies in a facility that has no power or running water, they are going to burn out.
An initiative needs to be deliberate in shifting this dynamic. A lot of African countries are training health care workers, but we end up losing them. They move abroad or work in the private sector. The US needs to be cognizant of how we are losing workers and consider training and retention packages, what works for the region and how to ensure absorption. The program needs to be tailored to the context of our region and utilize task-shifting. Mid-level cadres and community health care workers are bearing the biggest burden, and the bulk of the resources and investments should go there. But of course, that doesn’t exclude the need on the other hand to invest in specialist cadres, based on growing disease burdens and specialized programs. We have seen what for instance targeted investment in different priority cadres to deliver, for instance, Maternal and Child Health services, HIV, etc., has done to program delivery. Its about getting the right skills mix.
We have good examples of previous good, well-rounded donor investments that have shown impact and the US will need to critically learn from these programs. PEPFAR’s investments in HRH, USAID, and HRH2030, and other initiatives have shown good track records and impact.
At country level there are other initiatives too. There was a well-known story at one time that alludes to the mobility, migration of health care workers and challenges of shortages of health care workers in African countries, and this story was that one time there were more Malawian Doctors in Manchester, England than in all of Malawi itself. This was not quite accurate, but it is true that most of the specialized and skilled health care workers countries train would not be retained and those sent outside to specialize would hardly return. So, the US must consider how its initiative will address and innovate around the implementation and adherence of the voluntary WHO Code of Practice on the International Mobility and Recruitment of Health Care Workers.
To address these issues, we need a long-term investment to get real results. Take for instance Malawi’s Emergency Human Resource for Health Plan. This was a 4–6-year investment in a holistic approach and it worked.
It is good to hear that the White House wants to address issues related to gender and equity, since 70% of the workforce are women. We need to empower women, since that is an investment in broader economic development.
Have you seen US approaches change over time?
I have followed PEPFAR’s approach and investments very closely, particularly in HRH. I think they have a good structure, and they have done a good job improving the health workforce in Africa. Previously, they had so much parallel work, with USG programs paying workers at way higher levels and that wasn’t sustainable. We have seen them now harmonizing that work. And harmonization, alignment, and standardization to country led plans is key for the sustainability of the program.
I think one challenge that we have seen also is the lack of coordination, alignment, and harmonization of HRH investments by donors. PEPFAR is working on this now by trying to set up HRH joint inventories with the Global Fund, but I would like to see Gavi, GFF, UNICEF, and others come to the table too in terms of clear, country-level plans that coordinate and align, and at the same time are led by governments, with clear plans for pulling out and handover strategies, and negotiated with not just ministries of health but also the ministries of finance. The US through PEPFAR and USAID already have the leverage to support governments to bring this together, using the resources of this initiative. And that’s what the example of the EHRP Malawi project demonstrates, as a country-led plan, funded by multi-stakeholders, multi-faceted and multiple priorities, clear timelines, and monitoring and evaluation frameworks, etc.
Do you think any particular US agency should lead the initiative?
I feel strongly that we need to channel this through the agency that has the expertise, and USAID in close coordination with PEPFAR of course has that expertise. USAID in close coordination with PEPFAR is the technical and lead agency when it comes to implementation and sub granting.
Do you think your country or others in the region are ready to invest more in the workforce? Could a US initiative help encourage that?
Definitely, yes. The reality is that governments are stuck, to a large extent, and when you have a look at the national health budgets and really break them down, you will find over 60-80% is actually HRH, and one wonders how any other programs are being funded. Of course, we know it’s donors that are funding other programs. While others may argue and see this as an excuse not to act, and simply insist governments invest more in HRH, the reality is there is limited fiscal space. Until we have an initiative that addresses the issues I raised earlier on debt, illicit financial flows, and the need for progressive taxation, as the elephants in the room, and corruption of course, we will still have limited public funding for health, which then trickles to limited funding for HRH and it creates a vicious cycle. And so smart investments need to be extremely innovative, and catalytic and be willing to take risks and address and dive into and touch on topics that no one is quite addressing yet to find lasting solutions that are critical. That would be the real game changer in the long term.
As civil society organizations, we agree governments should invest more in HRH, and we continue to push and lobby them to do more, but they just don’t have enough resources. Given the mobility and retention challenges discussed, this needs to be seen as a shared responsibility, a global public good investment and a win-win situation.
We see a vicious cycle that governments are in since they are so heavily dependent on donors. A lot of governments are willing to invest in HRH, but we need to look at the fiscal policies and restrictions that exist. For example, World Bank and IMF have restrictions on wages, yet to invest in the health sector we need funds for wages. The Biden initiative needs to be innovative and look at these issues too. We must remove fiscal policies that are preventing investment and take on the debt issue.
Should the US utilize multilateral efforts like Gavi, Global Fund, and the GFF?
Yes I would want to see this initiative as a catalytic fund that would attract other interests and investments from other governments that want to invest but don’t have the know-how of how to go about it, nor the infrastructure outside of the bilateral space. I wouldn’t want only the US investing.
While it is a great thing, and might be highly recommended, to channel through USAID/PEPFAR, the danger is that you are excluding other countries that would support with a multilateral investment.
How do we motivate other countries to invest as well—France, UK, Canada and Germany? There is also a multiparter trust fund and the Working for Health Initiative, which is specifically investing in HRH, and currently developing its strategic Plan for the next few years, and it has a good program and huge funding needs.
We also have the ACT-A’s Health Systems and Response Connector, which is poorly funded and with a current focus on HRH-only provision of PPE, yet at country level it is clear that HRH is the barrier and biggest challenge. HRH investment will need to be first and central in any future pandemic preparedness conversations and there is need to put investment amounts that are not an afterthought or left-over figure but should be taken as a separate and key priority of its own. US leadership would promote and motivate other governments to step in as well on this.
I would say both bilateral and multi-lateral are needed for additional mobilized resources. The options exist in GF, Gavi, GFF, ACT-A and Multi-Partner Trust Fund and the Interagency Working for Health Initiative, by WHO, ILO, and the OECD. Most important is how the US will use this initiative to also bring some innovation, alignment, coordination to this fragmented space in terms of global financing for HRH.
Amanda Banda is global health advocate at Wemos in the East and Southern African region. She focuses on Human Resources for Health and Finance for Health programs. Amanda is also co-chair of the Health Workers For All Coalition.
Amanda has over ten years of experience influencing national governments in Africa, global health institutes and donors; holding them accountable; and calling for them to prioritize investments in health. She has also worked in South Africa, Lesotho, Mozambique, Malawi, Zimbabwe, Kenya, Uganda, the Democratic Republic of the Congo, Guinea, and the global context.
Prior to joining Wemos, she was part of the Health Politics team of Médecins Sans Frontières as HIV Advocacy Coordinator in charge of the African region. In this position, she coordinated and led multi-country advocacy work supporting the organization to influence the global HIV agenda, while at the same time analyzing the global HIV political and economic environments for the organization.
Amanda has experience in supporting civil society organizations engagement in key national and global health agendas and investment decisions and is an ally of many local, national and global civil society organizations. She has a background in International Relations and Political Science at universities in Zimbabwe and South Africa.