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GHIs and Health Workforce – The Importance of State Ownership and Actor Coordination: Field Perspectives from Burundi and South Africa

Author(s): J. Cailhol*1, T. Mathole1, A. Parsons1, T. Niyongabo2, D. Sanders1
Affiliation(s): 1School of Public Health, University of Western Cape, Bellville, South Africa, 2National Center for HIV Reference, Bujumbura, Burundi
Keywords: Global Health Initiatives, Human Resources for Health, Burundi, South Africa

Burundi and South Africa are virtually opposite countries: Burundi is a post conflict and poorly resourced country with a low HIV prevalence while post apartheid South Africa is a middle-income country with a high HIV prevalence. However, both countries experience a significant shortage of human resources for health (HRH), though affecting Burundi to a greater extent. Both countries have also in common 2 Global Health Initiatives (GHIs), PEPFAR and GFATM. In Burundi, the Permanent Executive Secretary of the National AIDS Council (PES-NAC) has been the principal GFATM recipient since 2003. Funds were not disbursed to the Ministry of Health, considered at that time unreliable. The PES-NAC sub-contracted NGOs to deliver HIV-related services and advised PEPFAR on its NGO implementation. In South Africa, GFATM funds have been provided through government health departments and PEPFAR has historically directly funded NGOs.

Methods: The impact of GHIs on HRH in Burundi and South Africa was assessed as part of the INCO-DEV “Experience of 5 African countries with GHIs” study (2006-2010) and as part of the WHO “Maximizing Positive Synergies between GHIs and health systems” study (2009). Qualitative data were collected from national-level and from 3 provinces inBurundi and in South Africa. National-level interview participants included key stakeholders from both government and donors’ institutions. In each province, key-informants were interviewed from a sample of facilities andNGOs. Thematic content analysis was used to analyse qualitative data and results were triangulated with documentanalysis and quantitative data from NGOs and facilities. We report here preliminary results on HRH. We focus onhow the employment of HRH for HIV activities was handled in Burundi, exploring its consequences and structural,organisational and contextual factors. We then discuss these results in relation to experiences in South Africa.

Burundi’s post-conflict context did not allow the state to manage GHI funding or to predict their effects on HRH. The public sector, perceived as unable to deliver services, was ignored and the focus placed on sub-contracting NGOs. The scarcity of HRH pushed NGOs to provide decent salaries to attract and retain HRH. This reduced coordination possibilities between NGOs and public sector. By contrast, South African health authorities seemed to exert strong leadership and ownership of GFATM and latterly PEPFAR funds, controlling HRH terms of employment and often coordinating NGO activities. However, the extent of such coordination and ownership depended on the capacity of local government. These countries’ experiences with GHIs could be explained by their backgrounds and show the importance of government organizational structures and ownership in HRH planning and management. A country’s capacity to negotiate and plan GHI activities may also be related to GHIs’ contributions to national health expenditure.

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