A total of 13 countries from the Eastern Mediterranean Region are included in this study. These are Afghanistan, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Jordan , Morocco, Pakistan, Somalia, Sudan, Syrian Arab Republic, Tunisia, and Yemen. Of these 13 countries, nine are currently funded. Four countries are not currently funded as of 2018, but they have received grants in the past. Phases 1 and 2 of this study focuses on the 13 countries listed in Table 1 that are previous and current grant recipients. About half of these countries are in the lower-middle income category (Table 1). With respect to HRH density, the results show that Global Fund recipient countries continue to have physician and nurse/midwife HRH densities below the regional average in the EMR region, based on the most recent data available. However, physician and nurse HRH densities have generally trended upwards from earliest years to most recent years of funding (Table 1).
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As shown in Table 2, based on the quantitative analysis of the 13 grant recipients that received Global Fund funding at some point over the period 2003-2017, we estimate about US$2.2 billion in budgeted funding from Global Fund grants and US$1.6 billion in Global Fund grant expenditure. Budgetary allocations to human resources for health (training and human resources) as a percentage of total budget range from 15% in Yemen to 35% in Tunisia. Similarly, actual expenditures as a percentage of total expenditure range from 17% in Yemen to 40% in Tunisia. Figure 3 shows that budgetary allocations to and spending on human resources for health (training and human resources) are 27% of total budget (US$599 million) and 28% of total expenditure (US$454 million), respectively.
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Analysis of the total amount of human resources/training budget and expenditure allocated by income level, disease category, and Global Fund region is shown in Figure 4. As shown, about 60% of the total human resources/training budget and expenditure is allocated to HR/training in lower-middle income countries, probably reflecting the fact that more (about half) of the countries in our analysis are in the lower-middle income category. We find that about 37% of total HR/training allocation in the study countries is for TB, while 26% is for malaria. About 32% of total HR/training budget and 34% of total HR/training expenditure are for HIV/AIDS. Some grants are designated entirely for health system strengthening activities. About 5% of total budget allocation to HR/training and 3% of total HR/training expenditure across all grants from 2003-2017 are within the health systems strengthening/resilient and sustainable systems for health (HSS/RSSH) component.
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Using the “direct” estimates of HRH (HR and training) budgetary allocation from the detailed budget data from 2015-2017, we show that 10 countries in the region are recipients of Global Fund grants within this 3-year period. As shown in Table 3, 36% of total grants’ budgets from the Global Fund are allocated to HR and training (or TRC) between 2015-2017. However, analysis of only the line items that are specific to “direct” investments to local health workers (e.g. excluding payment to grant management workers) shows that 13% of total budget is allocated to ‘direct’ HRH (HR and training).
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Using the in-depth results of the two case study countries, Afghanistan and Sudan, we find evidence for specific HR and training activities that have been influenced by Global Fund investments. As shown in Table 4, as of December 2017, a total of 32 grants have been awarded to both countries with 7 grants allocated to HIV/AIDS, 11 grants for Malaria, 10 grants for TB, and 3 grants for HSS/RSSH across both countries, while 1 grant has been awarded jointly for all three disease categories (HIV/AIDS, TB and malaria) in Afghanistan. The US$ 647 million and US$ 491 million in Sudan account for 29% and 30% of all budget and expenditure to the entire region respectively. The US$ 233 million and US$ 152 million in Afghanistan account for 11% and 9% of all budget and expenditure to the entire region respectively (Table 2). In Afghanistan, the principal recipients for the grants are evenly distributed between government and private/non-government organizations. In Sudan, almost all grants are administered by the United Nations Development Programme.
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In Afghanistan, as shown in Table 5, Global Fund financing has been instrumental in supporting both in-service and pre-service trainings with the aim of building the capacities of health sector personnel in the country. The beneficiaries of in-service trainings include national program officers; provincial program officers; health management information systems officers; or clinical staff, such as medical doctors, nurses, community health workers, community health supervisors, and lab technicians. One pre-service training program that the Global Fund invested heavily in is the Community Health Nursing Education program that provides a two-year training for female community health nurses with a focus on health needs of rural populations, as well as specific diseases including HIV/AIDS, TB and malaria. The graduates, who make formal commitments to serve their community for 3-5 years after graduation, are also involved in other relevant community health activities, such as home visits and supportive supervision of community health workers. Six hundred and seventy-three community nurses (a 97% completion rate) have graduated from this program, and a 2016 assessment showed an estimated 59% of program graduates had been deployed to public health facilities in their communities (16).
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Similarly, in Sudan, Global Fund has supported both pre-service and in-service training. Global Fund provided some funding for infrastructure (e.g. vehicles and rehabilitation of buildings) to the Academy of Health Sciences, which was established by the Ministry of Health in 2005 to train health professionals, including nurses and community health workers. An example of pre-service training though this academy is the primary health care expansion program targeted at producing primary health care cadres, namely community health worker/volunteers, through a 9-month training program in integrated primary health care delivery. Global Fund financing has also played a role in the functioning of Continuous Professional Development (CPD) centers which were established to provide in-service training through short courses for all levels and disciplines of health cadres in alignment with the country’s needs. An example of a CPD in-service training is a 45-day bridging course for medical assistants to receive on-the-job training in integrated care provision. Support has also been provided for various in-service trainings for health workers involved in HIV/AIDS, TB and malaria control programs.
The case study results with regard to hiring, contracting, recruitment, and compensation of health care workers in Afghanistan and Sudan indicate that the Global Fund does not provide direct salary support for health workers. This is due to Global Fund and government policies, as well as concerns about sustainability and health worker motivation. Hence, Global Fund’s influence in this regard in Afghanistan is mainly through the payment of incentives or top-ups for health workers, such as health workers who have worked in TB treatment and prevention as well as outreach workers at internally displaced peoples’ camps. According to the public health ministry’s policies, funds for incentives could not exceed 10% of the payroll costs of the individual facility or 5% of the payroll costs of the grant or contract. Global Fund also supported top-up payments to health care workers in Sudan until 2016, but currently is not investing in such payments.
Regarding the level of coordination between Global Fund supported HRH-related activities and national governments’ programming, in Afghanistan, in-service trainings funded by Global Fund are launched in close collaboration with the Ministry of Public Health. The planning, training materials and implementation of these trainings is done by the national HIV/AIDS, TB and malaria disease programs. There are noted gaps in information management related to tracking and keeping records on the number of trainees across agencies and donors. In Sudan, there is coordination between the government and donors for some activities. For example, the creation of “One Plan” by the Federal Ministry of Health is to ensure complementarity, harmonization and reduction in duplication of donor-supported activities. Hence, Global Fund-supported activities are directed to identified areas of need that complement other donor-supported programs. In addition, relevant stakeholders discuss how to deploy the investments from the Global Fund to ensure alignment with the goals of the Ministry of Health and the needs of the country. For example, the discussion on how resources provided to the Academies of Health Sciences were to be utilized took place between the officials of the academy, the Ministry of Health, other relevant government agencies, and the Global Fund.