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Summary

The United States government, under the Global Health Initiative, has issued a Principle Paper on Health Systems Strengthening. This Statement responds to that paper on behalf of the Frontline Health Workers Coalition. The Coalition commends many of the elements of the paper. We also provide specific recommendations for follow up that would address issues not included in the paper and/or facilitate application of findings in the paper. The Coalition recommends that the concerned US government agencies (notably, USAID, OGAC, CDC and HRSA) take the following steps in concert:

• Provide technical guidance to country-based US government teams on critical human resources for health (HRH) issues.
• Develop and apply clear, objective criteria to guide resource allocation as among countries benefiting from US HRH assistance.
• Define and apply metrics to assess HRH progress.
• Delineate and use a comprehensive approach to HRH assistance programs.
• Invest in a carefully developed HRH research agenda to address critical knowledge gaps.
• Acknowledge and clarify the role that partners play in delivering the HRH assistance program.
• Integrate the role of clients and communities into their approach to HRH.
• Incorporate the dimension of organizational culture into their approach to HRH.

The Frontline Health Workers Coalition invites dialogue with the concerned US government agencies on these recommendations and welcomes the opportunity to support continued advancement of the US effort to address the global health workforce crisis.

GHI Principle Paper on Health System Strengthening

The Frontline Health Workers Coalition (FHWC) has reviewed with great interest the Global Health Initiative (GHI) Principle Paper on Health Systems Strengthening (HSS). This paper is one of a series intended to elucidate the approach to the GHI principles. FHWC is dedicated to constructive dialogue with the US government on responding to the global health workforce crisis. Since human resources for health (HRH) is one of the HSS building blocks, we issue this statement to share our perspective after studying this important document. FHWC congratulates GHI and the authors for undertaking this effort. We appreciate the effort to "…share information, ideas, resources and challenges…" emanating from the USG experience. We know this was a serious and painstaking exercise. While FHWC recognizes that this was a paper looking at the entirety of HSS, and we reviewed it as such, we did take special interest in the sections that specifically addressed HRH. FHWC especially commends the following elements of the paper:

• Clarification of the USG’s conceptualization of HSS and approaches to HSS;
• Presentation of a very interesting framework integrating the “relational” and “functional” approaches, which shows the interdependence of the HSS building blocks;
• Discussion of the relationship between HSS programs and disease-specific programs;
• Useful categorization of discrete HSS activities;
• Positive examples of “joint programming” that co-funded HSS investments from different sources;
• Discussion of inter-agency collaboration, including positive examples where this has worked well;
• Advocacy for investments in HSS “activities that have the greatest potential to improve health outcomes and impact”;
• Interesting examples of collaboration with other donors;
• Acknowledgment that strengthening HRH includes a broad array of personnel from clinicians to accountants;
• Comprehensive view of pre-service education and in-service training, including training staff on site, supporting local faculty development, strengthening medical education, etc.
• Emphasis on country ownership; e.g., Nicaraguan MOH reforms, Nepal MOH budget platform;
• Good descriptions of counter-productive USG behaviors; and,
• Numerous short descriptions of interesting projects and interventions.

Observations and recommendations

This paper is a good beginning to an important conversation. Our suggestions are intended not as a critique of the paper, but rather as constructive proposals for follow up. We observe that the paper is clear that, “It is not formal guidance, a policy directive, a strategy, a toolkit, a user’s manual, or a blueprint.” To our knowledge, the USG has not issued policy directives, strategies, toolkits, user manuals or blueprints for HSS in general or, more specifically for HRH. While there are many talented people and fine projects working on HSS and HRH, this absence of coherent guidance is troubling. The paper quite correctly points out that health systems are “a binding constraint” to further and sustained progress in health. We find it hard to imagine that senior officials at USAID or CDC would argue that the US child survival assistance program should operate without a strategy, plan or formal guidance. Yet the absence of a well articulated approach for addressing the binding constraint of weak health systems persists. We believe this gap must be remedied. We very much like the paper’s explicit recognition of the interdependence of the HSS building blocks. Each block relies on the good functioning of the others and a systemic approach is needed. Though health workforce constraints are critical and pervasive, we acknowledge that HRH remains just one important aspect of a complex system. That said, the Frontline Health Workers Coalition is focused on the human resource issue. We believe that strengthening human resources merits special attention. Ultimately, the other building blocks largely exist for the purpose of supporting the interaction between accessible, well trained, supplied and highly motivated health providers and their clients. To that end, we suggest below some follow-up actions to the HSS Principle Paper that we think would prove useful to both USG teams and implementing partners:

1. Technical guidance: Consider issuing HRH technical papers under USAID aegis that provide guidance to the field. The HSS Principle Paper perforce offers very cursory treatment of many critical issues. Consequently, it is not clear how, if at all, it would actually be used in the field since the discussions lack adequate depth to be a guide to programming or action. For example, performance based financing is highlighted as a key USG approach, though the evidence summit on this subject concluded that it should be applied cautiously and only under certain conditions. Similarly, we are very supportive of efforts to follow up on the Community Health Worker (CHW) Evidence Summit to be sure that the USG is supporting best practices consistently in this arena. The HSS Principle Paper speaks approvingly of joint programming and suggest some good examples, but offers little practical advice on to design, implement, assess and finance such efforts, especially in light of the contradictory pull of disease-specific programs that provide the money. There are abundant resources that can be drawn on in developing such technical guidance, often developed under USG funding. However, they have not been systematically codified and transmitted to the field in a form that can help shape programming constructively.
2. Resource allocation: One of the hallmarks of USG programming at it best is the use of objective criteria to drive resource allocation. For example, the severity and magnitude of child mortality and HIV prevalence are critical to the allocation of child survival and HIV/AIDS funds, respectively. This application of public health criteria is laudable.  The HSS Principle Paper does not address this topic. We do not know if such criteria exist within the USG for the allocation of resources devoted to HRH or if they are applied. If they do exist, it would be helpful to share those with the implementing partners. If they do not, we recommend the development of clear criteria that could help optimize the allocation of resources as between countries. These might include health worker density, key health indicators such as child and maternal mortality, health expenditures per capita, and the priority for other USG health programs. This would help ensure that funds are going where they are most needed and will have the greatest impact. We recognize that public health indicators will be only part of the decision-making process, but they should at least be an important consideration.
3. Metrics: The HSS Principle Paper raises the issue of measuring progress, but is less than definitive about how the USG will accomplish this. The paper states that a consensus of HSS indicators, including HRH indicators, remains “elusive”. We concur that a global consensus is missing – as has been true for decades. But it does not seem wise to defer indefinitely assessment of the outputs and outcomes of USG investment in HRH until a global consensus has been achieved. This is a case where the perfect has truly become the enemy of the good.A plethora of HRH indicators have been defined; it may be better to systematically track a subset of indicators that can serve as bellwethers of progress rather than be paralyzed by too many indicators. For example, OGAC’s assertion that PEPFAR is on track to reach the target of training 140,000 new health workers must rest on a methodology that could be more broadly applied. Alternatively, a proxy measure, such as the Health Workers Reach Index might adopted by the USG. Yet a third possibility is to accelerate progress on incipient efforts to develop a Health Workforce Effort Score modeled on the Family Planning Effort Score.
4. Comprehensive approach to HRH programming: A better approach to baseline measurement might also encourage a more comprehensive approach to programming. The HSS Principle Paper asserts that all 27 approved GHI strategies available at the time the paper was written include health workforce. We wonder if this is same assertion would be made if the definition of HRH extended beyond training to such issues HRH planning, policy and management; recruitment and retention; and/or productivity and quality. Our concern derives from the potential waste of time and resources if training is not accompanied by other interventions that make it more likely new health workers will succeed. We suggest that USG country programs be careful not to simply conflate training with addressing the health workforce crisis.
5. Research: We applaud the HSS Principle Paper’s call for more research on health systems strengthening. While much has been learned, there are still significant gaps in knowledge, especially in applying general concepts and tools to specific contexts. It would be helpful to pursue this line of reasoning by developing a research agenda in collaboration with experts and scholars specializing in HRH. A reasonable degree of funding should be set aside to support research that has the potential for broad applicability.
6. Partnerships: The interesting discussion of collaboration is heavily focused on the USG relationship with recipient governments and other bilateral and multilateral donors. Relatively little attention is paid to the role of either non-governmental organizations (NGOs) or the for-profit sector. Yet, in many countries, these two sectors deliver much or most of the health services. While there are USAID projects that support these two sectors, it would be useful for the USG to clearly articulate its approach to providers outside of government.We also suggest that, perhaps as part of the technical guidance, lessons learned and best practices about the interaction among the government, for-profits and NGOs should be distilled. In particular, the government sets the legal and regulatory framework that can encourage or inhibit the appropriate contribution of for-profit entities and NGOs. A good example would be guidance on best practices for the regulatory framework governing task sharing.Much of the USG contribution to strengthening HRH and other dimensions of HSS is done with and through implementing partners. It would be helpful for the USG to articulate how it can most productively collaborate with the implementing partners, taking into account consultation with the partners.
7. Client and community: One interesting lesson to be taken from the recent CHW Evidence Summit is the explicit recognition that the CHW requires the support of the broader health system and depends upon the support of the community in which the worker is embedded. A client-centered approach should be at the core of the approach to HRH and HSS. A purely functional point of view may not give adequate attention to the relationship between health workers and the clients, households and communities they serve. More explicit attention to these relations might be useful as part of follow to the HSS Principle paper.
8. Organizational culture: In our view, an important missing element from the entire discussion of HRH and HSS is organizational culture. The norms, values and expectations are as critical as the specific management systems to the efficacy of an organization. There is abundant research that such factors as autonomy, the opportunities for mastery and a sense of purpose are what really drive whether workers in any organization are effective, including organizations delivering health care. In future USG approaches to HRH, we hope these factors can be more explicitly taken into consideration.

FHWC reiterates that we found the HSS Principle Paper to be a very helpful and thoughtful document. We are grateful to the authors for their contributions to our collective thinking. We believe that it should be followed with concrete steps that will help expand and strengthen the USG contribution to HSS, especially HRH. This statement is issued in the spirit of making constructive recommendations that we hope will further our shared goals. FHWC welcomes dialogue with the concerned USG agencies to discuss our recommendations and to see how continuing progress on HRH and HSS can be supported. For further information, please contact Susan O'Halloran (sohalloran@savechildren.org), Mary Beth Powers (mpowers@savechildren.org) or Maurice Middleberg (mmiddleberg@intrahealth.org) This statement was issued on behalf of the Frontline Health Workers Coalition. It does not necessarily represent the views of any of the Coalition members or its donors.