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    • The Role of the United States and Japan on Human Resources for Health in Developing Countries:
    An independent Policy Review from The Civil Society of the United States and Japan

    This book is the outcome of the research funded by the Center for Global Partnership, Japan Foundation

    The Role of the United States of America and Japan for Human Resources for Health Engagement in Developing Countries: An Independent Policy Review from the US and Japanese Civil Society

    Africa Japan Forum
    Health Workforce Advocacy Initiative

    Acknowledgement

    We express our deep appreciation for all of the people who supported our research.
    We express our deep appreciation for the colleagues of Health Workforce Advocacy Initiative and its Secretariat, Physicians for Human Rights.
    We express our deep appreciation for Center of Global Partnership, Japan Foundation, which funded our research.

    Masaki Inaba
    Program Director for Global Health
    Africa Japan Forum

    Contents

    Executive Summary

    Global attention on the global shortage of health workers has moved with speed over the last several years, spurred by prominent reports as those of the Joint Learning Initiative on Human Resources for Health (2004) and the World Health Organization (the 2006 World Health Report). The 2008 Hokkaido Toya-ko G8 Summit in Japan gave unprecedented levels of attention to HRH for a G8 summit. Such attention has culminated in a call for global targets and even HRH commitments by donor nations. More recently, in September 2010, the UN Secretary-General’s Global Strategy for Women's and Children's Health called for up to 3.5 million health workers to “dramatically improve access to life-saving interventions for the most vulnerable women and children in the [world’s] 49 poorest countries.”[1]

    Over the past several years, a variety of initiatives and reports have addressed health system strengthening more broadly, such as WHO’s important renewed focus on primary health care and on universal health coverage, the U.S. President’s Global Health Initiative, and the joint Global Fund-GAVI-World Bank Health Systems Funding Platform. The increasing emphasis on health system strengthening as core to the global health agenda is altogether appropriate and necessary. It is important to acknowledge that there significant barriers to quality health services besides health worker shortages, and simply adding more health workers to dysfunctional health systems can and will have only limited impact.

    Actions aimed at resolving the health workforce crisis requires the sustained political and policy attention, investments, and engagement of a variety of actors and stakeholder including developing and developed governments, civil society, and the private sector. There is need for considerably accelerated progress and scaled up investment if the HRH crisis is to be effectively managed and positive health outcomes achieved in global health. Notwithstanding the recent past, the profile and importance of the global health workforce shortage remains o far from the debates on effective global health strategies and efforts. Progress at global and national levels have been too slow and investments in the health workforce largely inadequate to achieve the type and quality of focus required for lasting change at country level.

    In recent years, only two G8 nations have committed to specific HRH targets, Japan and the United States. These commitments represent global HRH leadership while at the same time illustrate the challenge faced by donor governments in addressing health workforce shortages in developing countries and the clear need for broader engagement by others.

    This paper reviews both Japanese and U.S. commitments to health workforce and makes recommendations on would be needed to strengthen these efforts, including strengthen overall foreign aid to improve health systems and the health workforces designed to work within them. The following shortened recommendations are presented in full later in the proceeding chapters of this paper.

    [1]UN Global Strategy for Women's and Children's Health (2010),http://www.who.int/pmnch/activities/jointactionplan/201009_globalstrategy_6lang/en/index.html


    U.S. Recommendations
    Recommendations as part of PEPFAR’s objectives and 5-year strategy requirement:

    1. Train and support retention of health workers, with the target of training and retaining at least 140,000 new health care professionals and paraprofessionals with an emphasis on training and in country deployment of critically needed doctors and nurses.
      • The U.S. must ensure that PEPFAR has the necessary funding to fully implement its HRH commitment, and do so while fully carrying out other aspects of PEPFAR, and should therefore increase appropriations in FY’12 and FY’13 to ensure a total appropriations of at least the authorized $48 billion for FY’09 through FY’13 for U.S. global AIDS, tuberculosis, and malaria programs.
      • PEPFAR should help build a significant pipeline of additional doctors, nurses, and other health professional and paraprofessional cadres who will graduate both by the end of FY’13 and in later years. Measures should include helping to hire and retain additional instructors, expanding the physical capacity of health training institutions, strengthening management capacity of these institutions, and supporting innovative educational strategies such as increased use of distance and e-learning.
      • PEPFAR should ensure countries have needed funding to employee these health workers, support retention strategies for new and existing health workers including scholarships linked to a commitment to serve in-country, financial and non-financial incentives, improved management and enhanced professional development opportunities.
      • PEPFAR should develop a comprehensive strategy, by country, to maximize the extent to which the recruitment of students into health training institutions and their educational experience countries to their retention and deployment in areas of greatest need, which would in general include:
        1. Recruitment from rural areas, urban slums, and other particularly underserved areas, and from poor and other marginalized populations, including linguistic minorities;
        2. Scholarships, remedial educational efforts, and other measures as may be needed to retain students, including those from poorer families or with a weaker educational background;
        3. Curriculum reform to address the population’s major health needs;
        4. Incorporating human rights education, including on the right to health, into the curricula of pre-service training institutions;
        5. Ensuring mentors for students who can guide students to rewarding careers of service in their countries among populations most in need of their services, and;
        6. Ensuring sufficient mentorship, guidance, and other support for health professionals, particularly during their first several years of service.
    2. PEPFAR should publicly provide information, by country, to monitor compliance with this Congressional target and effectiveness of measures undertaken, including:
      • ensuring that these are in fact new health workers;
      • the types of new health workers being trained, and;
      • specific retention measures and their effectiveness.
    3. PEPFAR should employ indicators to measure PEPFAR support for the equitable and effective deployment and retention of health workers. These indicators should, so far as possible, be harmonized with indicators used by the host country.
    4. PEPFAR should support all countries in developing human resources information systems to enable effective planning and to real-time monitoring.
    5. PEPFAR should support local researchers in operational research on effective measures to retain and equitably deploy health workers, and to incorporate findings into local and national policies.
    6. Support countries in efforts to achieve at least 2.3 doctors, nurses, and midwives per 1,000 population, as called for by the World Health Organization
      • PEPFAR should help provide support for training and supporting the retention of more than 140,000 new health workers; achieving 2.3 doctors, nurses, and midwives per 1,000 population, along with corresponding numbers of other cadres, would require 1.5 million new health workers in Africa alone.
    7. Help countries develop and implement national health workforce strategies
      • PEPFAR must support the development of national health workforce strategies and ensure such strategies are needs-based, comprehensive, costed, grounded in human rights principles, developed with wide participation, and linked to an overall national health strategy.
      • PEPFAR should provide technical and financial support to countries receiving significant PEPFAR assistance to implement such plans.
      • PEPFAR should support efforts that ensure these strategies are to be fully funded. To the extent possible, PEPFAR should fill in, at a minimum, critical resource gaps toward full implementation.
      • PEPFAR should help build the capacity of governments to effectively engage development partners to develop a coordinated HRH (and health sector) funding strategy, including national resources, bilateral assistance, and multilateral opportunities, to enable the full and predictable funding of HRH strategies.
      • PEPFAR should engage HRH technical working groups or other multi-stakeholder national HRH bodies to ensure that its HRH activities support national HRH priorities. PEPFAR should also help build the capacity of such bodies and provide related support, such as to enable them have broad multi-sectoral representation, including multiple ministries, civil society, health professional and other health worker associations, and private sector.
      • PEPFAR should help build the capacity of civil society to be able to effectively engage in local and national HRH planning, monitoring, and evaluation, including to participate in local and national budget processes, and including to hold the government and other health system actors accountable to health plans, policies, and commitments, including right to health obligations. This should including support for national civil society-led HRH or broader health coalitions.
      • PEPFAR should support community efforts to ensuring the effectiveness and accountability of local health services, such as through regular monitoring of and feedback to local health services and responsibility authorities, effective dialogue with these authorities, as well as engagement with the media and with legal and political processes.
      • PEPFAR should support civil society, government, and media efforts to educate the public on their health-related rights and HRH policies, and mechanisms and processes through which they can assert these rights and hold the government and other health actors accountable to these rights and policies.
      • PEPFAR should support health worker associations to enable them to exercise their leadership and other functions.
    8. Advance safe working conditions for health care workers
      • PEPFAR should develop and implement policies to ensure safe working conditions for all health workers who participate in PEPFAR and other U.S. government-supported global health programs.
    9. Strive to achieve goals in training, retaining, and effectively deploying health staff
      • Along with training and retention efforts, PEPFAR should engage in a comprehensive set of strategies ? such as incentives, scholarships, recruitment from rural areas, and rural health infrastructure investments ? to support deployment of health workers to where they are most needed, including rural and other “hardship” areas, such as urban slums.
      • PEPFAR should support countries in developing more efficient, fair, and transparent health worker recruitment processes.
    10. Promote use of codes of conduct for ethical recruiting practices for health care workers
      • PEPFAR should help publicize and encourage adherence to the Global Code of Practice on the International Recruitment of Health Personnel and the Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States.

    Japanese Recommendations

    1. Japan should take a global political leadership in highlighting the HRH Crisis and setting global targets and strategies.
      • Set a global numerical target for additional HRH in developing countries and win global consensus.
      • Create and fund global strategy to strengthen HRH in developing countries, including adequate and sustained resource mobilization
    2. Japan should ensure the following in the creation of a global strategy to strengthen HRH
      • Strengthening HRH does not end at training. Tackling the HRH crisis requires a strategy that creates a cycle of training, hiring, equitable deployment and retention to ensure that large numbers of quality health workers stay at the public health sector.
      • The strategy must include the creation and support of health administrators at the central and local governments with high level knowledge/capacity in managing the process of training, hiring and retention of health workers.
    3. Provide adequate financing for health workforce development that is proportional to the economic scale of Japan. Specifically, at the least, triple the amount of bilateral and double the amount of multilateral ODA to global health.
    4. Japan should set a clear and concrete financial target for its support for human resources for health.
    5. Ensure meaningful multi-stakeholder involvement in the creation, implementation and evaluation of the comprehensive policy
      • The comprehensive strategy should be developed with the involvement of all stakeholders.
    6. Create a bold vision and comprehensive policy, based on the needs/gaps of the partner countries and weaknesses of the current global aid for global health and utilizing Japan's comparative advantage and Human Security.

    back to TOP

    (Part 1)Strengthening Japanese Response to Health Workforce Crisis in Developing Countries: Findings and Recommendations on Japanese Approach to HRH

    Introduction

    The critical global shortage of health workers moved with remarkable speed from the margins to the center of the global health agenda several years ago, spurred by such prominent reports as those of the Joint Learning Initiative on Human Resources for Health (2004) and the World Health Organization (the 2006 World Health Report). This attention culminated in 2007 and 2008 with a special focus on the health workforce as part of the International Health Partnership, and the First Global Forum on Human Resources for Health (HRH) in March 2008, and its Kampala Declaration and Agenda for Global Action. The 2008 Hokkaido Toya-ko G8 Summit in Japan gave unprecedented levels of attention to HRH for a G8 summit, which came as the U.S. government committed to train and support the retention of at least 140,000 new health workers in development countries, while Japan committed to train 100,000 health workers in Africa. This period also saw the launch of a high-level taskforce on innovative international financing for health systems that was framed in large part as a way to raise significant and predictable funds to help meet health workforce needs and achieve the Millennium Development Goals (MDGs) by 2015. More recently, in September 2010, the UN Secretary-General’s Global Strategy for Women's and Children's Health called for up to 3.5 million health workers to “dramatically improve access to life-saving interventions for the most vulnerable women and children in the [world’s] 49 poorest countries.”[2]

    Over the past several years, a variety of initiatives and reports have addressed health system strengthening more broadly, such as WHO’s important renewed focus on primary health care and on universal health coverage, the U.S. President’s Global Health Initiative, and the joint Global Fund-GAVI-World Bank Health Systems Funding Platform. The growing emphasis on health system strengthening as core to the global health agenda is altogether appropriate and necessary. It is important to acknowledge that there significant barriers to quality health services besides health worker shortages, and simply adding more health workers to dysfunctional health systems can and will have only limited impact.

    It is far too soon, however, to allow resolving the health workforce crisis . from absolute shortages and severely inequitable distribution of health workers to shortcomings in quality and management . to cease to have a prominent place on national and global health agendas. Actions aimed at resolving the health workforce crisis still demand the sustained political and policy attention, investments, and engagement of a variety of actors and stakeholder including developing and developed governments, civil society, and the private sector. For despite notable advances in some countries, overall progress has remained limited. The need for considerably accelerated progress and scaled up investment in HRH remains crucial to improving global health.

    [2] UN Global Strategy for Women's and Children's Health (2010),
    http://www.who.int/pmnch/activities/jointactionplan/201009_globalstrategy_6lang/en/index.html



    Glancing Back, Looking Forward

    The last decade witnessed the launch of ambitious global health initiatives to improve the health and health outcomes of the world’s poor: the MDGs (2000), GAVI (2000), Global Fund (2002), PEPFAR (2003), WHO’s 3 by 5 Initiative, to highlight a few. While these initiatives have done a great deal to increase access to a variety of health interventions including antiretroviral treatment and immunizations, they were not initially designed with the need to transform fragile health systems. The indispensible role of health workers in providing care was largely at the periphery these. If health systems and health workforce had achieved greater focus from the beginning of these initiatives, might there have been greater advances with increased prospects of more sustained health improvements? Might health systems be stronger and more capable of meeting local and national need?

    This is changing. Over the past several years, initiatives such as the Global Fund, GAVI, and PEPFAR increased their focus on health systems, including HRH. The recent UN Secretary-General’s Global Strategy for Woman and Children, sets a global HRH target of up to 3.5 million health workers, between 2011 and 2015 to achieve MDGs 4 and 5. It illustrates, in clear terms, the urgent and critical need for skilled health workers and global action to improve health, particularly of woman and children. One of the five important areas highlighted in the Global Strategy is the need for “stronger health systems, with sufficient skilled health workers at their core” and the financial investments required so that “country-led health plans” are capable of providing “integrated delivery of health services and life-saving interventions.”[3]

    This call for strengthened health systems, envisions systems able to provide “integrated [and] high-quality services” that go beyond current capacity to reach communities and underserved areas and that effectively manage scarce resources including human and financial. The Global Strategy importantly draws attention to the need for policy-makers and other decision-makers to support increased health workforce capacity through national health plan development that can effectively addresses HRH challenges: “[Partners] must provide coordinated and coherent support to help countries develop and implement national health plans that include strategies to train, retain and deploy health workers.”[4]

    [3]UN Global Strategy for Women's and Children's Health (2010),
    http://www.who.int/pmnch/activities/jointactionplan/201009_globalstrategy_6lang/en/index.html
    [4]UN Global Strategy for Women's and Children's Health (2010), (pg. 7)
    http://www.who.int/pmnch/activities/jointactionplan/201009_globalstrategy_6lang/en/index.html



    Pulling HRH to the Center of Global Aid Architecture

    Efforts to strengthen health systems including human resources for health must come even as the global health architecture is being reworked. While developing health workforces that are appropriately trained, supported, and equitably deployed will not alone eliminate the large inequities in access to quality health goods and services, it is one indispensible element of improving health service delivery for all, especially the poor who presently have the least access. Strengthened health systems with a continuing emphasis on health workers must pulled to the center of the global health architecture -- and of national efforts to deliver quality care and services. No matter how ambitiously conceived, global health initiatives will fail to meet their aspirations without adequately addressing the resources and policies required for well-staffed health systems that can meet current and emerging health challenges. Health systems require the broad diversity of health workers from the highly skilled to the lay and community health workers who extend the health system beyond the clinic and directly into communities.

    After many years of disease-specific interventions focused on single infections such HIV/AIDS, TB, malaria, and polio, a consensus has emerged that health systems require greater, focused attention .even as the proper place of disease-focused programs and their impact on the broader health system remain subjects of debate. Some argue that these better-funded targeted interventions were carried out at the expense of health systems, such as by unintentionally attracting health workers and other staff away from poorly supported areas, such as primary care and maternal health, to HIV or other disease-focused programs, and away from clinics and hospital wards to administrative positions. Others argue that in environments where health systems were fragmented and ineffective, such programs in fact considerably strengthened health system, and created the present space for more concerted efforts around health system strengthening. Both perspectives are valid. To different degrees and in different ways, both dynamics have been at work. Increasing awareness of the importance of integration and health system strengthening, and understanding of possible harm, has led to considerable focus on how disease-focused programs can contribute to broader health system strengthening.

    The increased attention to health systems has gone hand-in-hand with increased recognition of the importance of country ownership and new types of partnerships. The Paris Declaration on Aid Effectiveness (2005) and the Accra Agendafor Action (2008) aim “to increase efforts in harmonization, alignment and managing aid for results with a set of monitorable actions and indicators.”5 During this same period, the WHO released Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes (2007), intended to develop “common understanding” of health systems and the activities needed to strengthen those systems. WHO’s Director-General noted, “the urgent need to improve the performance of health systems” if the MDGs are to be met by 2015, even taking into account the innovations and advancements in medical science and health care delivery.

    [5]http://www.oecd.org/document/18/0,3343,en_2649_3236398_35401554_1_1_1_1,00.html
    [6]http://www.who.int/healthsystems/strategy/everybodys_business.pdf



    HRH making difference yet insufficient to meet needs

    As highlighted in the Health Workforce Advocacy Initiative (HWAI) report, Achieving the MDGs by Investing in Human Resources for Health (2010), some countries are making notable progress towards increasing the size of their health workforce, enabling them to expand coverage of vital health services. For example:

    • In Malawi, more than 10,000 paid community health workers have been referred to as the country’s “most powerful weapon” in improving child health. Equipped with “medical checklists to aid them in diagnosing childhood killers and hardy bicycles to get around, they dispense medicines and give injections,” diagnosing and treating many childhood killers. The expansion of Malawi’s health workforce took place under their Emergency Human Resources Programme (EHRP) which included expanding training capacity and retention investments. Upon final evaluation, the EHRP led to a 53% increase in health professionals (in the public sector) between 2004 and 2009, and an overall 83% increase in all cadres counted including health surveillance assistants. In the public sector, health worker density increased by 66%. [7] Due to EHRP’s success and other factors, nurse migrating from Malawi declined from 108 to 16 between 2003 and 2009.[8] The increased number of health workers greatly contributed to expanded health service coverage and averted death. The number of public health facilities with the staff needed to offer AIDS treatment increased from 24 in 2003 to 339 in 2009. During the same years, the proportion of health facilities that offered Malawi’s Essential Health Package increased from 9% to 74%. The proportion of deliveries attended by skilled personnel increased from 38% in 2004 to 52% in 2009. The assessment of the EHRP found more than 13,000 additional lives saved due to the expanded health service coverage that the EHRP enabled for just a set of four aspects of maternal and child health: (1) antenatal care, (2) deliveries by trained staff, (3) fully immunized children, and (4) administration of Nevirapine to prevent vertical HIV transmission. [9][10]
    • In Zambia, in the pilot phase of a 2003 retention scheme . now receiving support from the United States, the Netherlands, and other partners . 69 physicians were deployed in rural areas on three-year contracts. The health workers received hardship and accommodation allowances, education allowances for the doctors’ children, eligibility and some funding for post-service training, and eligibility for a loan. PEPFAR, which early in the pilot supported 30-35 physicians, reported that its support enabled 5,000 people to receive ART who would not previously had access to AIDS treatment. The program has since been expanded to include more physicians and to also cover other cadres of health workers (e.g., nurse and health science tutors, nurses, and clinical officers). By 2008, 232 health workers were enrolled in the retention scheme, with plans to expand to more than 1,600 health workers. The scheme placed doctors in all 54 rural districts, the majority of which did not have a single doctor before the rural retention program. The scheme has drawn at least twenty physicians to back to Zambia from abroad. [11]
    • Ethiopia’s Health Extension Worker Programme was launched in 2003 to reach universal access to primary health care by 2009 and expand health care coverage by providing one year of training to 30,000 health extension workers to be deployed to village posts. As a result of the initiative, “[c]overage of publicly-funded health care [rose] from 61% in 2003 to 87% in 2007.” [12] Management Sciences for Health noted that independent assessment showed that the HEWs helped prevent communicable diseases and enabled community participation in health sector planning and implementation.
    • Between 2005 and 2009, Rwanda implemented an effective tripartite set of reforms to strengthen the health system: performance-based financing, community-based health insurance, and quality assurance. The performance-based financing lead to reforms that improved staff motivation, quality, and access to care by increased financial resources at the operational level and provided important information for decision-making purposes. Most notably, the reforms: (1) increased contraceptive use among married women from 10% to 36% between 2005 and 2008; (2) increased deliveries attended by skilled birth attendants from 31% to 52% between 2005 and 2007; and (3) reduced child mortality from 152 per 1,000 live births to 103 per 1,000 live births between 2005 and 2007.[13]

    Despite these and other promising measures to address health workforce challenges, much more must be done. Persisting health worker shortages remain a critical barrier to the provision of care and quality services. Developing and developed nations must combine efforts and coordinate responses to implement adequate and appropriate measures that effectively address the global shortage of health workers, particularly to invest in the health workforce and health more broadly, as well as to respond to the negative impacts of health worker migration and restrictive macroeconomic policies that limit fiscal space and prevent governments from making needed investments in health and health workforce.



    [7]Mary O’Neill, Zina Jarrah, Leonard Nkosi, et al. (Management Sciences for Health) & Harold Kuchande & Albert Mlambala (Management Solutions Consulting), Evaluation of Malawi’s Emergency Human Resources Programme: EHRP Final Report (July 2, 2010), at 4, 28. Available at:
    http://www.who.int/entity/workforcealliance/media/news/2010/Malawi_MSH_MSC_EHRP_Final.pdf
    [8]Mary O’Neill, Zina Jarrah, Leonard Nkosi, et al. (Management Sciences for Health) & Harold Kuchande & Albert Mlambala (Management Solutions Consulting), Evaluation of Malawi’s Emergency Human Resources Programme: EHRP Final Report (July 2, 2010), at 16. Available at:
    /http://www.who.int/entity/workforcealliance/media/news/2010/Malawi_MSH_MSC_EHRP_Final.pdf
    [9]Health Workforce Advocacy Initiative, “Financial resources for human resources: Strategies to mobilize funding for the health workforce.” (August 2010), at 11-12
    [10]Mary O’Neill, Zina Jarrah, Leonard Nkosi, et al. (Management Sciences for Health) & Harold Kuchande & Albert Mlambala (Management Solutions Consulting), Evaluation of Malawi’s Emergency Human Resources Programme: EHRP Final Report (July 2, 2010), at 61-66. Available at:,
    http://www.who.int/entity/workforcealliance/media/news/2010/Malawi_MSH_MSC_EHRP_Final.pdf
    [11]Health Workforce Advocacy Initiative, “Financial resources for human resources: Strategies to mobilize funding for the health workforce.” (August 2010), at 13
    [12]http://www.msh.org/resource-center/publications/upload/Rwanda-EOP-11-10-09_spreads.pdf
    [13]Management Sciences for Health, A Vision for Health: Performance-Based Financing in Rwanda (Nov. 2009), at 4-5, 7. Available at:
    http://www.msh.org/resource-center/publications/upload/Rwanda-EOP-11-10-09_spreads.pdf

    US: Addressing HRH will require comprehensive strategies, policies and planning

    Only two G8 nations have committed to specific HRH targets . Japan and the United States. These commitments represent global HRHleadership while at the same time illustrating the challenge faced by donor governments in addressing health workforce shortages in developing countries and the clear need for broader engagement by others. This section draws attention to the US Government’s HRH efforts.

    In July 2008, the legislation re-authorizing the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) gave the program a new emphasis on HRH. The new law required PEPFAR to “train and support retention of health care professionals and paraprofessionals, with the target of training and retaining at least 140,000 new health care professionals and paraprofessionals with an emphasis on…critically needed doctors and nurses[.]” The legislation requires PEPFAR to help countries develop and implementation national health workforce strategies, advance safe working conditions for health workers, and promote codes of practice on ethical recruitment. The following year, the Obama Administration launched the Global Health Initiative (GHI). The GHI, with PEPFAR as its “cornerstone,” seeks to strengthen health systems while making important investments in health workers. Among other important priorities, GHI documentation highlights that the initiative will focus on “improving human resources for health by training additional health workers; deploying workers; motivating, mentoring and retaining trained workers” and strengthening health systems by “increasing numbers of trained health workers and community workers appropriately deployed in the country.” Such language illustrates the broadening of efforts that go beyond implementing disease specific interventions to improving health systems and ensuring long-term sustainability.

    To achieve a robust and comprehensive approach to the PEPFAR HRH requirement and fulfill GHI’s promised emphasis on HRH, Physicians for Human Rights developed a series of recommendations that center on supporting implementation of health workforce strategies including “improving human resource management, achieving equitable deployment, and enhancing health worker health and safety, while providing additional support for training and retention.”14 The following recommendations aim to achieve a robust and full response on HRH. Building on and incorporating PEPFAR, the GHI is well-positioned to work alongside countries to strengthen health workforces and the systems in which they work. To achieve the broadest and sustainable success, PEPFAR requires significant health workforce and health system investments, and must develop forward-looking policies and provide bold leadership in its collaborations.


    Recommendations as part of PEPFAR's objectives and 5-year strategy requirement:

    1. Train and support retention of health workers, with the target of training and retaining at least 140,000 new health care professionals and paraprofessionals with an emphasis on training and in country deployment of critically needed doctors and nurses.
      • The U.S. must ensure that PEPFAR has the necessary funding to fully implement its HRH commitment, and do so while fully carrying out other aspects of PEPFAR, and should therefore increase appropriations in FY'12 and FY'13 to ensure a total appropriations of at least the authorized $48 billion for FY'09 through FY'13 for U.S. global AIDS, tuberculosis, and malaria programs.
      • PEPFAR should help build a significant pipeline of additional doctors, nurses, and other health professional and paraprofessional cadres who will graduate both by the end of FY'13 and in later years. Measures should include helping to hire and retain additional instructors, expanding the physical capacity of health training institutions, strengthening management capacity of these institutions, and supporting innovative educational strategies such as increased use of distance and e-learning.
      • PEPFAR should ensure countries have needed funding to employee these health workers, support retention strategies for new and existing health workers including scholarships linked to a commitment to serve in-country, financial and non-financial incentives, improved management and enhanced professional development opportunities.
      • PEPFAR should develop a comprehensive strategy, by country, to maximize the extent to which the recruitment of students into health training institutions and their educational experience countries to their retention and deployment in areas of greatest need, which would in general include:
        1. Recruitment from rural areas, urban slums, and other particularly underserved areas, and from poor and other marginalized populations, including linguistic minorities;
        2. Scholarships, remedial educational efforts, and other measures as may be needed to retain students, including those from poorer families or with a weaker educational background;
        3. Curriculum reform to address the population's major health needs;
        4. Incorporating human rights education, including on the right to health, into the curricula of pre-service training institutions;
        5. Ensuring mentors for students who can guide students to rewarding careers of service in their countries among populations most in need of their services, and;
        6. Ensuring sufficient mentorship, guidance, and other support for health professionals, particularly during their first several years of service.
      • PEPFAR should publicly provide information, by country, to monitor compliance with this Congressional target and effectiveness of measures undertaken, including:
        1. ensuring that these are in fact new health workers;
        2. the types of new health workers being trained, and;
        3. specific retention measures and their effectiveness.
      • PEPFAR should employ indicators to measure PEPFAR support for the equitable and effective deployment and retention of health workers. These indicators should, so far as possible, be harmonized with indicators used by the host country.
      • PEPFAR should support all countries in developing human resources information systems to enable effective planning and to real-time monitoring.
      • PEPFAR should support local researchers in operational research on effective measures to retain and equitably deploy health workers, and to incorporate findings into local and national policies.
    2. Support countries in efforts to achieve at least 2.3 doctors, nurses, and midwives per 1,000 population, as called for by the World Health Organization
      • PEPFAR should help provide support for training and supporting the retention of more than 140,000 new health workers; achieving 2.3 doctors, nurses, and midwives per 1,000 population, along with corresponding numbers of other cadres, would require 1.5 million new health workers in Africa alone.
    3. Help countries develop and implement national health workforce strategies
      • PEPFAR must support the development of national health workforce strategies and ensure such strategies are needs-based, comprehensive, costed, grounded in human rights principles, developed with wide participation, and linked to an overall national health strategy.
      • PEPFAR should provide technical and financial support to countries receiving significant PEPFAR assistance to implement such plans.
      • PEPFAR should support efforts that ensure these strategies are to be fully funded. To the extent possible, PEPFAR should fill in, at a minimum, critical resource gaps toward full implementation.
      • PEPFAR should help build the capacity of governments to effectively engage development partners to develop a coordinated HRH (and health sector) funding strategy, including national resources, bilateral assistance, and multilateral opportunities, to enable the full and predictable funding of HRH strategies.
      • PEPFAR should engage HRH technical working groups or other multi-stakeholder national HRH bodies to ensure that its HRH activities support national HRH priorities. PEPFAR should also help build the capacity of such bodies and provide related support, such as to enable them have broad multi-sectoral representation, including multiple ministries, civil society, health professional and other health worker associations, and private sector.
      • PEPFAR should help build the capacity of civil society to be able to effectively engage in local and national HRH planning, monitoring, and evaluation, including to participate in local and national budget processes, and including to hold the government and other health system actors accountable to health plans, policies, and commitments, including right to health obligations. This should including support for national civil society-led HRH or broader health coalitions.
      • PEPFAR should support community efforts to ensuring the effectiveness and accountability of local health services, such as through regular monitoring of and feedback to local health services and responsibility authorities, effective dialogue with these authorities, as well as engagement with the media and with legal and political processes.
      • PEPFAR should support civil society, government, and media efforts to educate the public on their health-related rights and HRH policies, and mechanisms and processes through which they can assert these rights and hold the government and other health actors accountable to these rights and policies.
      • PEPFAR should support health worker associations to enable them to exercise their leadership and other functions.
    4. Advance safe working conditions for health care workers
      • PEPFAR should develop and implement policies to ensure safe working conditions for all health workers who participate in PEPFAR and other U.S. government-supported global health programs.
    5. Strive to achieve goals in training, retaining, and effectively deploying health staff
      • Along with training and retention efforts, PEPFAR should engage in a comprehensive set of strategies - such as incentives, scholarships, recruitment from rural areas, and rural health infrastructure investments - to support deployment of health workers to where they are most needed, including rural and other "hardship" areas, such as urban slums.
      • PEPFAR should support countries in developing more efficient, fair, and transparent health worker recruitment processes.
    6. Promote use of codes of conduct for ethical recruiting practices for health care workers
      • PEPFAR should help publicize and encourage adherence to the Global Code of Practice on the International Recruitment of Health Personnel and the Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States.


    Other recommendations

    The USG's HRH strategy on achieving a scale-up of health workers after 3 years remains imprecise at best. In considering an effective approach to achieve the GHI's HRH objectives, IntraHealth proposes useful components of an effective strategy, including:[15]

    1. Identify priority countries: It is relatively unclear which countries the GHI intends to target to achieve the 140,000 within PEPFAR. With limited capacity, it is necessary to manage available resource so as to achieve largest possible success: "By having a set of priority countries the resources of these projects could be properly directed to serve a larger strategy advancing progress in HRH." [16]
    2. Building the constituency for HRH:, HRH coalitions represent an important and undervalued element in achieving HRH success. Effectively resourced and informed with accurate and up-to-date data and information, coalitions can be highly effective in advocating on a range of topics intended to improve conditions and ensure local needs are met: "HRH advocacy requires building a diverse coalition that includes respected leaders and champions, represents an array of concerned constituencies, and does the hard work of building agreement around a platform of action that is evidence-based and responsive to local needs." [17]
    3. Set key indicators and assess progress: It is important that performance be measured assess progress toward reaching our goals. Despite, varying levels of complexity and difficulty in measurement, it is critical that a series of indicators be put in place and measured in order to see our progress and ensure efforts are most effective. IntraHealth proposes five initial indicators:[18]
      1. Total number of health workers (relative to the population)
      2. Total number of health workers (relative to the population) by region of the country
      3. Total number of new health workers (relative to the size of the health workforce)
      4. Ratio of exits from the health workforce
      5. Relative number of specific tasks performed among health workers
    4. Develop HRH leadership within USG: USAID has a strong history focusing on health workers. With the historic commitment to train and retain 140,000 new health workers, a new and bold leadership is needed if this and other HRH efforts are to be successful. IntraHealth rightly proposes establishing a new position of an HRH coordinator: "[An] HRH coordinator should be established within USAID. This person would be responsible for managing the development of a government-wide HRH strategy and have authority over the proposed budget of approximately $550 million per year. The HRH coordinator would have the mandate to coordinate HRH development across agencies and receive regular progress reports from the concerned offices and agencies."[19]

    [15]Saving lives, ensuring a legacy: A health workforce strategy for the Global Health Initiative,
    www.intrahealth.org/.../saving-lives-ensuring-a-legacy-a-health-workforce-strategy-for-the-global-health-initiative/IntraHealth
    [16]Ibid.
    [17]Ibid.
    [18]Ibid.

    Call for Global HRH target including financing

    To sustainably and significantly improve health outcomes and effectively address the global HRH crisis, the U.S. and Japan cannot stand as the only wealthy countries with measurable HRH commitments. Leadership on HRH must be widely shared at global and national levels, with broad and concerted support from an inclusive range of stakeholders. The Health Workforce Advocacy Initiative (HWAI), in consultation with various civil society stakeholders, has called for "bolder leadership; clear, time-specific targets; and increased financial resources at global and national levels." Presented at the 2nd Global Forum on Human Resource for Health in Bangkok, Thailand, in January 2011, the following global and country-level recommendations were proposed as immediate steps that the World Health Organization, the Global Health Workforce Alliance, and national governments should take:

    Global HRH and Financial Targets

    1. Step up campaigns to meet HRH targets that are informed by national realities and that begin with funding to have at least 3.5 million new health workers in training or hired and equitably deployed by 2015.
    2. Develop a post-2015 goal to close the health workforce gap, drawing and improving upon WHO's 2006 minimum need estimate of 4.1 health workers per 1,000 population.
    3. Publicly commit to a financial target greater than $40 billion for 2011 through 2015) that includes the additional HRH financing needed for all countries with critical local and national shortages.
    4. Facilitate reversal of macroeconomic policies that result in "sub-additionality" (or when donor aid replaces government spending without being additive) and restrict health investments.
    5. Launch a global HRH campaign to ensure that countries, development partners, and HRH stakeholders adopt these targets and cooperate in their achievement.

    Country-level Targets and Strategies

    1. Develop and implement fully-costed, needs-, evidence-, and rights-based health and health workforce plans with health worker-, patient-, and civil society-organization involvement in their development, implementation, and monitoring and evaluation; identify the needed skills mix and health workforce density targets; set country-based goals for the production, equitable deployment, support, and retention of health workers; and mobilize additional funding needed.
    2. Strengthen HRH management and policy development to effectively coordinate multi-stakeholder and multi-sectoral involvement and guarantee accountability at all levels.
    3. Maximize opportunities to work with global health initiatives such as the Global Fund, GAVI and PEPFAR to increase co-investments in HRH and health system strengthening.
    4. Improve systems for educating, hiring, and equitably deploying all cadres of health workers and incentivizing quality service delivery, continuing professional development and long-term retention.

    Rising to the challenge of the global health worker shortage

    1. The global shortage of health workers poses one of the greatest challenges to health and development for developing nations. Despite increasing attention on the chronic global shortage of health workers and real progress in some countries, much more must be done to meet local need and prevent unnecessary suffering. The U.S. and Japanese HRH commitments offer examples of global leadership to help address the inadequate supply, distribution and retention of health workers, yet even these efforts require strengthening. By enhancing their own efforts, the United States and Japan can position themselves to be even more effective global leaders in addressing the global health workforce crisis - and in the process, and in conjunction with the leadership of developing countries that have made significant progress on HRH, can make historic contributions to overcoming one of the greatest obstacles to ensuring that all people have access to the quality health services to which they have a right, and which will save millions of lives.

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    (Part 2) Strengthening Japanese Response to Health Workforce Crisis in Developing Countries: Findings and Recommendations on Japanese Approach to HRH

    ISSUE 1: A CALL FOR JAPAN'S INTERNATIONAL LEADERSHIP IN HRH

    Since 2000, Japan has been setting the trend in global health policy. At the 2000 Okinawa G8 Summit, where Japan chaired the G8, Japan launched the Okinawa Infectious Disease Initiative and called for the need of an international financing mechanism to dramatically increase resources to fight infectious diseases. As a result, fighting infectious disease has been mainstreamed into the international global health discourse and led to the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

    From 2007 to 2008, when discussions on global health strategy discourse between disease specific initiatives and comprehensive health system strengthening was reaching its peak, Japan, as part of the G8 Toya-ko Summit process, convened a series of meetings of health experts to create the Toya-ko Framework for Action on Global Health.

    In 2006, two years before the G8 Toya-ko Summit, the international community increasingly recognized the deepening health crisis facing developing countries due to the shortage of HRH, international brain drain and movement of health workers from public to private NGO health sectors. As a result, Global Health Workforce Alliance (GHWA) was created as a common platform for action to address this crisis. In March of 2008, GHWA sponsored the First Global Forum on Human Resource for Health, where participants adopted the Kampala Declaration and Agenda for Global Action. Despite the international agreement to tackle the global HRH shortage, the Kampala Declaration lacked both an international target on HRH training, hiring and retention, and an international strategy to mobilize resources and technical support. The UK-lead initiative, IHP+, brought further attention on the issues of coordination and resources for health systems strengthening, but it did not lead to global mobilization around HRH. Donor countries continued "business as usual" bilateral aid without necessarily focusing on strengthening HRH or in cases where countries were investing HRH through bilateral aid, they lacked cooperation with other donor countries and global mechanisms.

    Since the G8 Toya-ko Summit, Japan increased its support for GHWA and HRH issues. Japan, at some of the highest level of government showed support for GHWA by dispatching JICA staff to its secretariat or by co-hosting the Second Global Forum on Human Resources for Health which took place in January 2011 in Bangkok. Furthermore, in 2011, Dr. Masato Mugitani, Assistant Minister for Global Health of Japanese Ministry of Health, Labor and Welfare has been named the new board chair of GHWA. Japan should take advantage of the high government support for HRH and take leadership in mainstreaming the HRH crisis in the global health policy. Furthermore, Japan should take leadership in creating an international target and strategy that tackles public sector HRH crisis in the public sector in developing countries and provides new funding and action for long term, sustainable health system strengthening and increased production and retention of HRH.

    ISSUE 1 RECOMMENDATIONS

    1. Japan should take a global political leadership in highlighting the HRH Crisis and setting global targets and strategies.
      • Set a global numerical target for additional HRH in developing countries and win global consensus.
      • Create and fund global strategy to strengthen HRH in developing countries, including adequate and sustained resource mobilization.
    2. Japan should ensure the following in the creation of a global strategy to strengthen HRH
      • Strengthening HRH does not end at training. Tackling the HRH crisis requires a strategy that creates a cycle of training, hiring, equitable deployment and retention to ensure that large numbers of quality health workers stay at the public health sector.
      • The strategy must include the creation and support of health administrators at the central and local governments with high level knowledge/capacity in managing the process of training, hiring and retention of health workers.

    ISSUE 2: DRASTIC INCREASE IN JAPANESE AID IN GLOBAL HEALTH

    The other challenge lies in the amount of Japanese budget allocated to bilateral global health. In 2009, Japan, the second largest economy in the developed world, provided USD 270.83 Million in bilateral aid (grant aid and technical cooperation) for global health. In comparison, UK provided USD 967.19 Million, Germany USD 479.85 Million, Norway USD 252.49 Million. Despite Japan declaring global health as a priority of Japanese developmental aid, the volume of bilateral aid by Japan is severely inadequate compared to other countries. Furthermore, within its bilateral aid, there is no dedicated funding stream to HRH and Health system strengthening.

    ISSUE 2 RECOMMENDATIONS

    1. Provide adequate financing for health workforce development that is proportional to the economic scale of Japan. Specifically, at the least, triple the amount of bilateral and double the amount of multilateral ODA to global health.
    2. Japan should set a clear and concrete financial target for its support for human resources for health.

    ISSUE 3: A BOLD VISION AND COMREHENSIVE AID STRATEGY FOR HRH

    Japan has continually called on the importance of training health workers and the strengthening of health systems as keys to achieving the Millennium Development Goals. Japan soon turned HRH and health systems strengthening (HSS) as one of the pillar issues in Japan's development aid for health. Despite acknowledging the need to tackle the health workforce crisis, Japans has yet to translate the "need" into a comprehensive, actionable strategy or provide the adequate financing to contribute meaningfully and sustainably to addressing HRH shortages and weak health systems.

    In 1994, Japan's first policy document on global health, Global Issues Initiative on Population and AIDS was released, followed in 2000 by the Okinawa Infectious Diseases Initiative and in 2005, the Health and Development Initiative. The extent to which these documents that claims be Japan's global health policy, could translate into impact on the ground is limited, as it misses key components needed in a policy including goals, allocated budget, target countries and methodology. Components on health care workers and HSS are contained throughout the documents but are left scattered without any comprehensive and concrete policy directives.

    Beginning in 2007, the shift in global discourse on health brought increased recognition on HRH and HSS. Following this trend, in 2008, the G8, led by Japan released the Toya-ko Framework for Action on Global Health, highlighting the importance of training and retention of the health care workers. In 2010, at the High Level Plenary Meeting on the 65th Session of the UN General Assembly on the Millennium Development Goals, Prime Minister Naoto Kan launched a successor to the 2005 Health and Development Initiative. There were high expectations amid the increased focus on HRH, that the New Global Health Policy 2011-2015 would finally contain concrete policy directives on tackling the human resource crisis. However, the new policy did not live up to its expectations.

    The New Global Health Policy 2011-2015, Japan's five-year development policy on global health contains three major components of maternal, newborn, and child health (MNCH), major infectious diseases and contribution to global public health emergencies. Focusing on MNCH (especially on the reduction of under-five mortality rate), Japan recommended a model to strengthen the linkage between community and health facilities. It was named "EMBRACE Model" (Ensure Mothers and Babies Regular Access to Care). Although the training and retention of human resource for health is woven into the model, there is neither a clear vision nor comprehensive policy on the health workforce crisis.

    The following highlights the challenges of the New Global Health Policy 2011-2015:

    1. Since the First Global Forum on Human Resource for Health in 2008, Japan has actively taken part in HRH issues, such as the steering of GHWA. However, the policy paper does not contain any Japanese commitment for HRH.
    2. Japan has continuously put the development of health workers at the center in Japanese involvement in global health. However, Japan fails to redefine and expand its mandate and actions under the new global trend for HRH that has emerged since the establishment of GHWA in 2006. The EMBRACE MODEL, the new Japanese imitative for Maternal and Child health was introduced as one the pillars of the New Global Health Policy 2011-2015. However, the new policy lacks any coherence between the attainment of this EMBRACE MODEL relates the development of Health Workers or clarity on how it relates to the current HRH crisis.
    3. Despite Japan International Cooperation Agency (JICA) investing large sums of financial and human resources in the implementation of the following activities (mentioned below), and claiming that these activities are vital in Japan's contributions for HRH, it is not reflected at the policy level. There is no mention of these activities or its importance in the new global health policy.
      • Based on mutual trust between Japan and the Government of developing countries, JICA dispatches health experts to the central government to support the creation and implementation of the National HRH strategy.
      • JICA trains local administrators to conduct coherent and effective operations that are essential for carrying out health policies (e.g.: health management).
      • JICA introduced 5S-TQM (Total Quality Management), initially used as a quality control for Japanese companies, as a workplace organization methodology in health facilities in developing countries. JICA committed much human and financial resource to the implementation of the 5S-TQM, as it was believed to be vital in the strengthening of health systems and reducing the burden of health care workers.

    However, the responsibility of overcoming these challenges does not solely lie in the developers of Japans global health policy, the Ministry of Foreign Affairs. JICA has yet to provide sufficient explanation of its activities and evidence on how these activities contribute to overcoming HRH crisis.

    When explaining 5S-TQM, JICA tends to emphasize on the origin of this methodology (e.g. Japanese culture or development by Japanese companies to improve productivity), rather than explaining its relations to the HRH crisis or how 5S-TQM eases the burden on the health system and health care workers. As a result, at the field level, 5S-TQM is often seen only as an initiative to organize files and supplies. JICA needs to show how its activities fit into the global HRH picture.

    Whether it is the development of policies or implementation at the field level, the activities of each Japanese stakeholder (Ministry of Foreign Affairs, JICA, Ministry of Health, Labor and Welfare) in Global Health are fragmented. Each stakeholder conducts its activity unilaterally. Furthermore, each stakeholder conducts its activity as mandated or distributed under administrative law and hierarchal governmental structures, rather than their realistic capacity. As a result, Japanese global health policies introduced at the international level does not reflect the realities and capacities at the field level. (see Issue 4 for details)

    ISSUE 4: A MULTI STAKEHOLDER POLICY MAKING MECHANISM & A POLICY BASED ON HUMAN SECURITY

    Japan clearly indicates its support for the development of health care workers, making it one of Japans priority agenda within developmental aid. Translating this willingness to show real impact on the ground begins with the creation of clear, measurable and comprehensive objectives and comprehensive evidence based technical approach. However, without a bold vision and comprehensive policy, the extent to which Japan will support the development of health care workers remain unclear.

    Japan lacks not only the ability to make a comprehensive policy, but the ability to create a structure where a comprehensive policy can be made. This has been mentioned under Issue 2, but will be described in detail below:

    Currently, the Global Issues Cooperation Division of the Ministry of Foreign Affairs manages Japan's global health aid policy making process. JICA is included as the implementing entity but not seen as a partner in effective policy making that will make impact at the ground level. Furthermore, despite existing channels for dialogue exist between the Ministry of Foreign Affairs and Civil Society, the inputs of Civil Society are often watered down. Health experts, although having a higher level of influence than JICA and Civil Society, are still unable to play a central and proactive role in the policy making process. A top down approach by which the Ministry of Foreign Affairs manages the policy making process, and then thrown down to JICA and Civil Society for its implementation has distanced the implementers from taking ownership in Japan's global health policies.

    Furthermore, despite calling for human security to be the bases of Japanese aid for health, this principle is not effectively reflected in Japan's current global health policies. Nor has Japan created a policy based on its comparative advantage (See recommendations below) in the HRH and HSS area. Although there are examples of best practices from Japanese implementers that can turn into Japan's comparative advantage, this has largely remained best practices in a select few locations. To have impact on the health system and health resources at the country level, these good practices must be brought to the center of Japan's aid policy.

    ISSUE 3 and 4 RECOMMENDATIONS

    1. Ensure meaningful multi-stakeholder involvement in the creation, implementation and evaluation of the comprehensive policy
      • The comprehensive strategy should be developed with the involvement of all stakeholders. A multi-stakeholder committee that includes the Ministry of Foreign Affairs, JICA, Health Experts and Civil Society should be created to plan, implement and evaluate HRH policies. This committee will work as a team from the creation of the strategy, the implementation, the evaluation and if needed, the restructuring of the strategy. The Committee should also receive input from HRH/HSS Experts and implementing stakeholders in the field.
    2. Create a bold vision and comprehensive policy, based on the needs/gaps of the partner countries and weaknesses of the current global aid for global health and utilizing Japan's comparative advantage and Human Security.
      • Japan must set a bold vision and create a comprehensive strategy for strengthening HRH in developing countries. Japans should create a strategy based on HRH and HSS needs and reality of each country, Japan's comparative advantage, Gaps and weaknesses of current global aid for HRH, Human Security, and ensuring country ownership and donor coordination. The following are further descriptions of some of the components of the strategy.
      • HRH and HSS needs and reality of each country

      Japan must create HRH policy based on the fundamental concepts of:


      • The health crisis in developing countries is due to the vulnerability of health systems, including severe lack of HRH, and there is a need to strengthen the health systems, including filling the gap of HRH.
      • It is necessary, from the view of human security, human rights and global democracy, to secure access of all the people in the world, whenever and wherever, to qualified essential health services, and meaningfully participate in the efforts to improve health of their own communities.
      • People's access for essential health service should be achieved by creating sustainable health systems by ensuring governments protection for the health of its people and "empowerment" by the people and communities under the ownership of developing countries themselves. The role of international aid is to support financially and technically to these efforts of the communities and governments of developing countries.
      • Japan's comparative advantage

      Determine areas of aid where Japan has a comparative advantage, whether its examples of best practices from its projects or in comparison with other countries. These findings should be reflected at the center of Japans aid policy. Japans comparative advantage includes the following:


      • Japan strengthens HRH and HSS management capacity of the local government and administrative staff to cultivate ownership. This includes integrating health service delivery at local facilities with community-based health services.
      • Providing technical assistance to the central government to create and/or strengthen a national health strategy and implementation plan that best reflects the health systems and HRH realities and need of the country. Japan should also provide support to the local governments to ensure the implementation of the plan. Furthermore Japan should ensure the utilization of its bilateral aid to effectively implement the plan.
      • Japan supports local government and administration in a way that does not take away their ownership in building a health system to respond community needs.
      • Embodying the concept of Human Security

      Aid for HRH should be based on the concept of human security, one of the pillars of Japanese foreign policy and development aid. Japans aid for HRH should not be limited to strengthen HRH/HSS management and planning, but it should embody the concept of human security to plan and implement a need based aid. Global Health Aid based on Human Security includes both the responsibility of the government to protect the health of its people and the empowerment of the people to be able to promote their health.


      • Ensure the country can achieve human security of its people. This requires supporting countries to strengthen health system and health workforce that are self-sustainable in the long term, and for the government to take leadership and ownership to achieve human security of its people. Evidence shows that leadership at the highest level of governments for health has led to major improvements in meeting health targets.
      • Support the development of community response to health based on the realities and needs of that specific community. Furthermore strengthen cooperation between communities and primary health care facilities to create a better balance of responsibilities between community health and health care services.
      • From a human security perspective, Japan must guarantee the health and safety of health workers at hospitals and health centers and community health workers regardless of its seclusion, marginalization or in areas of conflict. A good working environment is essential in the retention of health care workers. Japan must recognize that the safety of the health care worker is a vital component in ensuring a good working environment. As Japan places human security as a pillar of its developmental aid, Japan could create a multilateral and bilateral initiative to protect health care workers.
      • Health care workers in the public sector in developing countries play a vital role in protecting the health of its people. However, there is a lack of understanding and appreciation from the public on the importance of health care workers in the public sector, and rather seen as a job that is extremely difficult without the proper financial compensation. Along with improving the work environment of the health care worker, there is a need to create understanding among its citizens on why health care workers in the public sector are important. To increase the publics respect for health care workers, some developing countries provides awards or creates movies/dramas on health care workers (e.g. Nigeria, Mexico and Egypt). Japan should support the creation of cultural and social initiatives that reshape the outlook for a new generation of prospective students to consider a career as a health care worker in developing countries, and to increase the trust and understanding between health workers and the communities they serve.
    3. Develop policies that ensures a shift from project to program based approach

      4. Japan should take a programmatic approach in the implementation of the above policies.


      • Maximize synergies: Increase synergies of existing schemes for project implementation, namely Grant Assistance, Technical Cooperation, Grant Assistance for Grassroots Human Security Projects, dispatch of JOCV, through a program-based approach. (about the details of "program-based approach, see Issue 5 for the details)
      • Create projects to meet program goals: New projects should fall under a program. These new projects should be able to utilize the schemes flexibly to ensure the attainment of the program goals and objectives.

    ISSUE 5: FLEXIBLE AND ADEQUATE FUNDING CHANNELS FOR BILATERAL AID

    Japans bilateral aid is inadequate with little flexibility to ensure that this comparatively small amount of money that trickles down to HRH can be used adequately.

    In addition to the inadequate funding level, Japan has designed a rigid funding scheme. Currently, the funding schemes available for HRH includes Grant Aid, Technical Cooperation Projects, Grant Assistance for Grassroots Human Security Projects, Grant Assistance for Japanese NGO Projects and dispatch of Japan Overseas Cooperation Volunteers (JOCV). Projects are developed to ensure that it fits the schemes. Thus, it is difficult to create synergy among projects with similar goals or objectives.

    In the past several years, Japan has shown some ambitions to move towards a program based approach that are more aligned to the national health strategy and Japans global health policy. However, it is sometimes difficult to find a positive outcome of the efforts. One reason for the stall in turning Japans ambitions for a programmatic approach into reality can be the shortage of JICA staff at the country level that has expertise in health program management. Even in cases where health experts are dispatched to countries, they are buried in the paperwork related to the schemes. Furthermore, local NGOs cannot directly receive funding from the Japanese government since the current schemes require contracts between the Japanese and the recipient country government.

    In countries where there is a shortfall in the national budget for health, Japan can help mitigate the shortage of health workers through direct health sector budget support. However, Japan has yet to invest directly into the government budget or invest in pooled funds which can make impact on much needed salary support or pre-service training of health care workers.

    Japan must strengthen its cooperation with both the implementing government and with different implementing agencies of donor countries, multilateral institutions, NGOs and local civil society at the country level. The government and all the development partners must understand each others strengths and weaknesses, and create a harmonized aid structure. However, in reality, there is a lack of understanding and cooperation in the implementing activities of each stakeholder at country level. To overcome this challenge, JICA should create staff positions at the country level that will be responsible for increasing cooperation with the different stakeholders

    ISSUE 5: RECOMMENDATIONS

    1. Provide dedicated funding to HRH while strengthening integration of HRH funding with existing funding for disease specific projects.
    2. Increase flexibilities in Japans' funding schemes that allows for the money to go to where it's most needed and best used. For example, creating a scheme that would allow direct funding to NGOs.
    3. Provide sector wide support and direct budget support for HRH pre-service training for new health care workers and retention for those already in service.
    4. Increase the number of staff responsible for global health in the JICA country offices. Furthermore, as JICA moves from project to a programme based approach, deploy experts to the field offices that will be responsible for program management and donor harmonization. Furthermore, create staff positions responsible for increasing cooperation among host country governments, donors, multilateral institutions, local civil society and Japanese NGOs at the field level.

    ISSUE 6: MONITORING AND EVALUATING HRH

    Recognizing the need to set targets and monitoring and evaluation determine the effectiveness of Japan's aid, the New Global Health Policy 2011-2015 calls for scientific, evidence-based targets for health. Japan has placed emphasis in outcome based indicators to use them as scientific evidence for determining the effectiveness of its aid.

    Evaluating the effectiveness of its aid on outcome based indicators is important. Following the new Global Health Policy, Japan is now trying to develop projects on health which can be evaluated through outcome-based indicators such as decrease in maternal and infant mortality rate or HIV infection rate. However, some investments in HRH and HSS are longer-term and may not have an immediate impact on these indicators. Outcome based indicators are not adequate to evaluate investments in strengthening HRH. Necessary targets should include the following:

    (1)Create and use input based target (e.g. production and retention of x amount of new health workers over annual baseline, based on meeting recognized international HCW density targets)
    (2)Create and set annual progress indicators in the attainment of the target
    (3)Create and set indicators that show non-numerical progress such as increase in knowledge and level of motivation

    On (1), the Japanese commitment to train 100,000 Health Workers and its implementation played out like a tragicomedy.

    In 2008, at the Tokyo International Conference on African Development IV, Japan adopted the Yokohama Plan of Action, with a commitment to "improvement of 1,000 facilities" and "training of 100,000 health workers". This commitment made two months following the First Global Forum on Human Resource for Health, received international attention for its numerical target to increase the number of HCW.

    However, in reality, this commitment was made without taking into consideration the technical and numerical capacity of the JICA, the implementing agency. Nor was this commitment was not matched with the necessary financial resource or made in harmonization with other development partners. The Japanese commitment was simply a number, as there is no comprehensive strategy on who will receive what kind of training and most importantly, how Africa's health workforce is going to be strengthened through the achievement of this commitment. A commitment made with such irresponsibility, both the implementing agency, JICA and the MoFA, the policy making entity showed no strong will or ownership to make this commitment meaningful to Africa's HCW crisis.

    Although Japan has made a commitment to the "training" of health care workers, there are no specific details on the content of the training or the length of the training. Thus, all training of Africans related to health care through Japanese ODA, regardless of length or content of the training was counted as "direct recipients" of training. Then assuming those who have directly received Japanese training would train other workers, Japan multiplied the number of each direct recipients by a fixed number of indirect recipients to calculate the number of those who received training from Japan. As a result, within a short period of two years, Japan was able to fulfill its commitment.

    This tragicomedy was a result of a commitment created without any clear and comprehensive strategy on how Japan can contribute to the HRH crisis. The commitment was to simply a number. The 100,000 commitment that received much international attention was "achieved". However, it did "achieve" anything in terms of how it has contributed to increasing the number of health care workers in Africa. Japan must learn the lessons of this tragicomedy. The commitment on the health workforce crisis must be

    1) clear and comprehensive target, 2) allocated resource commitment to achieve the target , 3) a comprehensive strategy on how this commitment will provide a meaningful contribution to the HCW crisis. Especially on the target of training health care workers, the target must specifically contribute to increasing the quantity of health care workers in the public sector with quality training. Furthermore, the target must be be meaningful of how the training fits into the overall cycle of training, hiring, equitable deployment and retention. Lastly, there must be a transparent monitoring and evaluation of the implementation of the target.

    Furthermore, on (3), a strengthened health workforce requires not just the increase of the number of health workers but ensuring that the health workers have the knowledge and motivation to work in the public sector. Indicators for knowledge and motivation already exist in fields such as education and industry. Japan should analyze and modify these existing indicators and adopt those indicators that will measure knowledge, motivation and length of rural posting in the health workforce. Japan needs work with other global partners to develop these targets and indicators of non numerical progress, using global health policy platform such as GHWA, the G8 as well as health media, (i.e. The Lancet), to ensure a strong target and indicators are adopted and implemented globally.

    ISSUE 6: RECOMMENDATIONS

    1. Set and create indicators for monitoring and evaluation that can measure progress towards global and national goals and the strength of the countries HS and HRH.
      • Set input based target (e.g. production and retention of new health workers over baselines of production, towards recognized international HCW density targets) with outcome-based indicators, Furthermore these targets and indicators must take into consideration equitable distribution and areas of the greatest need.
      • Create and set annual, numeric progress goals and indicators towards the attainment of the target
      • Create and set indicators that show non-numerical progress such as increase in knowledge and level of motivation
    2. HRH Targets should include the following:
      • Targets should be concrete, quantified as much as possible, and should contribute directly to increasing the quantity and quality of HRH. Targets should be set not only on pre-service and in-service training but also employment and retention.
      • Targets should be accompanied with sufficient financial commitment and appropriate comprehensive strategy to achieve them.
      • Monitoring and Evaluation of the progress of targets and strategy must be disclosed.

    ISSUE 7: AVOID AGGRESSIVE PURSUIT OF HEALTH CARE WORKERS FROM DEVELOPING COUNTRIES AND CREATE A SUSTAINABLE HEALTH SYSTEM IN JAPAN USING IN-COUNTRY RESOURCES TO FILL JAPAN'S HRH GAP

    The shortage of health care workers in developing countries' public sector is due significantly to the flow of health care workers to the private sector or high-income countries. Until recently, Japan, due partly to its strict immigration policies and high language and cultural barriers, was able to sustain its health system without the reliance of health workers in developing countries in comparison to other high-income countries.

    However, as the aging population is rapidly increasing, Japan is beginning to open its doors to workers from developing countries, especially nurses and care-workers. As the need for care-workers continues to grow in Japan, there is a high possibility that Japan will begin to aggressively pursue health care workers from developing countries. Furthermore, this trend could accelerate even more with the signing of Free Trade Agreements or Economic Partnership Agreements among countries in the Asia and the Pacific Japan must become self-reliant in expanding its own health workforce and must avoid poaching desperately needed health care workers from other countries.

    ISSUE 7: RECOMMENDATIONS

    1. Japan must evaluate its own health system to understand why it was able to maintain its low dependence, in comparison to other high-income countries, on health care workers from developing countries. As the need for care workers increase in Japan, it must find innovative ways to create a sustainable health system using in-country resources to fill the HRH gap.
    2. Adhere to the WHO Global Code of Practice on the International Recruitment of Health Personnel








    The Role of the United States and Japan on Human Resources for Health in Developing Countries
    An Independent Review from Civil Society of the US and Japan

    March 2011
    Africa Japan Forum
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    ○c2011　Africa Japan Forum


    This book was made as the outcome document of the research funded by Japan Foundation Center for Global Partnership. This research was done by Africa Japan Forum (Japan) and Health Workforce Advocacy Initiative (HWAI, the Secretariat of HWAI is Physicians for Human Rights).



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