title: Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening.
abstract: BACKGROUND
  Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), yet few studies have examined their effects on health systems.
  
  
  OBJECTIVE
  To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the largest investor in HRH outside national governments.
  
  
  METHODS
  We used mixed research methodology to analyse budget allocations and expenditures for HRH, including training, for 138 countries receiving money from the Global Fund during funding rounds 1-7. From these aggregate figures, we then identified 27 countries with the largest funding for human resources and training and examined all HRH-related performance indicators tracked in Global Fund grant reports. We used the results of these quantitative analyses to select six countries with substantial funding and varied characteristics-representing different regions and income levels for further in-depth study: Bangladesh (South and West Asia, low income), Ethiopia (Eastern Africa, low income), Honduras (Latin America, lower-middle income), Indonesia (South and West Asia, lower-middle income), Malawi (Southern Africa, low income) and Ukraine (Eastern Europe and Central Asia, upper-middle income). We used qualitative methods to gather information in each of the six countries through 159 interviews with key informants from 83 organizations. Using comparative case-study analysis, we examined Global Fund's interactions with other donors, as well as its HRH support and co-ordination within national health systems.
  
  
  RESULTS
  Around US$1.4 billion (23% of total US$5.1 billion) of grant funding was allocated to HRH by the 138 Global Fund recipient countries. In funding rounds 1-7, the six countries we studied in detail were awarded a total of 47 grants amounting to US$1.2 billion and HRH budgets of US$276 million, of which approximately half were invested in disease-focused in-service and short-term training activities. Countries employed a variety of mechanisms including salary top-ups, performance incentives, extra compensation and contracting of workers for part-time work, to pay health workers using Global Fund financing. Global Fund support for training and salary support was not co-ordinated with national strategic plans and there were major deficiencies in the data collected by the Global Fund to track HRH financing and to provide meaningful assessments of health system performance.
  
  
  CONCLUSIONS
  The narrow disease focus and lack of co-ordination with national governments call into question the efficiency of funding and sustainability of Global Fund investments in HRH and their effectiveness in strengthening recipient countries' health systems. The lessons that emerge from this analysis can be used by both the Global Fund and other donors to improve co-ordination of investments and the effectiveness of programmes in recipient countries.
authors.affiliation: Harvard School of Public Health, Boston, MA 02115, USA, Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, World Health Organization, 1211 Geneva 27, Switzerland and Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK r.atun@imperial.ac.uk.
authors.forename: Diana
authors.initials: D
authors.lastname: Bowser
authors.affiliation: Harvard School of Public Health, Boston, MA 02115, USA, Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, World Health Organization, 1211 Geneva 27, Switzerland and Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK r.atun@imperial.ac.uk.
authors.forename: Susan Powers
authors.initials: SP
authors.lastname: Sparkes
authors.affiliation: Harvard School of Public Health, Boston, MA 02115, USA, Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, World Health Organization, 1211 Geneva 27, Switzerland and Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK Harvard School of Public Health, Boston, MA 02115, USA, Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, World Health Organization, 1211 Geneva 27, Switzerland and Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Mitchell
authors.affiliation: Harvard School of Public Health, Boston, MA 02115, USA, Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, World Health Organization, 1211 Geneva 27, Switzerland and Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Bossert
authors.affiliation: Harvard School of Public Health, Boston, MA 02115, USA, Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, World Health Organization, 1211 Geneva 27, Switzerland and Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK.
authors.forename: Till
authors.initials: T
authors.lastname: Bärnighausen
authors.affiliation: Harvard School of Public Health, Boston, MA 02115, USA, Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, World Health Organization, 1211 Geneva 27, Switzerland and Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK.
authors.forename: Gulin
authors.initials: G
authors.lastname: Gedik
authors.affiliation: Harvard School of Public Health, Boston, MA 02115, USA, Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, World Health Organization, 1211 Geneva 27, Switzerland and Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK Harvard School of Public Health, Boston, MA 02115, USA, Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, World Health Organization, 1211 Geneva 27, Switzerland and Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK r.atun@imperial.ac.uk.
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000453:epidemiology / Q000517:prevention & control; D002017:Budgets; D005381:Financing, Organized / Q000191:economics*; D014943:Global Health / Q000191:economics*; D006302:Health Services Research; D006801:Humans; D007391:International Cooperation; D008288:Malaria / Q000453:epidemiology / Q000517:prevention & control; D009936:Organizational Innovation; D036301:Qualitative Research; D014376:Tuberculosis / Q000453:epidemiology / Q000517:prevention & control; D000078329:Workforce
keywords: Global Fund; Health systems; human resources for health