Development assistance for health workers and equity — is a Global Fund for Health the answer?
By Mariska Meurs, Global Health Advocate, Wemos Foundation
The shortages and unequitable distribution of health workers have been well known for many years. So are the challenges facing Official Development Assistance (ODA), including ODA for Health and in particular for health workers’ salaries. We need long-term sustainable funding for health.
Donors remain reluctant to commit to long-term and recurrent expenditures, such as health workers’ salaries. And recipient governments are understandably reluctant to accept foreign aid for salary payments, because of this lack of long-term commitments and the volatility of funding. There are several issues that hamper effective ODA allocation, such as a lack of predictability, insufficient alignment with country plans and fragmentation.
Mismatch in the health labour market
Yet several donors and recipient governments have been and still are prepared to try and overcome these hurdles. In Malawi for instance, donors have collaborated with the government in funding the Emergency Human Resources Plan (EHRP) already back in 2005. Recently, both the GFATM and PEPFAR have provided bridge funding to cover health workers’ salaries. Evaluations of the EHRP have pointed out that the program made a difference with a 53% increase in the number of health workers in the country.
However, despite large funds being invested in HRH over the years, a large mismatch remains between supply and need in the health labour market. The increase in health workers has not kept with population growth; Malawi had 1.99 doctors per 100,000 population in 2009 but that ratio decreased to 1.79 in 2016. In addition, a large number of trained health workers cannot be absorbed into the public sector due to budgetary and fiscal limitations.
Nothing new, nevertheless crucial
So what can we learn from these experiences, both past and present?
For a start, donors need to be prepared to be in it for the long run. This is admittedly not a new message at all, but it is one worth repeating. If a low-income country like Malawi, with low economic growth prospects, is able to finance just ten percent of the health workers needed to achieve UHC today, it is unlikely to have sufficient numbers, supported through domestic resources alone, a decade from now.
Secondly, adopting a comprehensive approach isn’t as widespread as it should be. Foreign aid is often focused on training or short-term objectives and seldom available — for a specific period of time — for paying salaries or salary top-ups. Other obstacles for a more equitable distribution of health workers include the lack of feasible housing, schooling and basic amenities in remote areas. Furthermore, drug shortages and supply chain issues obviously affect those working in hard to reach areas more than elsewhere.
Thirdly, the donor landscape still is highly fragmented and funds are often accountable to the taxpayers in high-income countries rather than to the people they intend to benefit. This can lead to misalignment between what is needed and what is on offer. In the case of health workers, mismatches continue between the cadres that are trained and those that are in shortest supply or between health workers that graduate and those that can be put to work in the public sector.
Health personnel: an investment
Nevertheless, I would like to conclude on a positive note, because it is good news that investing in health personnel is increasingly being seen as an investment. Even though donor funding for health workers’ salaries has its flaws, existing initiatives are laudable for trying and we need them to continue to learn and improve.
A global fund driven by needs
But ultimately what we need is long-term, sustainable, funding for health that adopts a comprehensive and cross-sectoral approach. Funding that is equitably raised and equitably spent. Can that be done via traditional ODA? Or via public-private partnerships that are increasingly being promoted by donors? I rather believe the answer lies in a global fund for health, one that pools resources, is based not on charity but rather on solidarity following a sense of global responsibility, which includes (international) taxes, and where allocations are driven by health needs instead of by the — be it well-intended — whims of donors.
