By Anne Mugisa, Irene Nabusoba
and Raymond Baguma

WHEN the Global Forum on Human Resources for Health convention ended last week with a call for big increases in the health-care work force, it left one very crucial question unanswered: Who is going to pay for it?

The 12-point ‘Kampala
Declaration’ adopted by about 1,000
participants, urged governments to
address the global crisis of shortage of health workers. But it offered no parallel commitments on funding.

As yet, there have been no concrete promises from governments, donors or the private sector to increase funding to boost the number of health workers through training and retention. In fact, forum leaders were even reluctant to estimate the cost of the changes they seek.

Sponsors said the event would
help build the political will to
increase the size of the health work force. Sceptics were dissatisfied.

“Where is the $70b for human
resources for health going to come
from?” asked the Health work force
Advocacy Alliance (HWAI), a civil
society network. “We demand that
governments, donor countries and
development partners stop the rhetoric and start the funding.”

A few would disagree that the situation is urgent. The World Health
Organisation (WHO) says 57 countries, most of them in Africa and Asia, face severe health work force shortages.

It says a total of 4,250,000 new doctors, nurses and other health
providers are needed to fill the gap.
The problem is, especially serious
in Africa, which has 25% of the
global burden of disease, but only
3% of the world’s health workers.

In Africa, 36 countries have fewer
than 2.3 doctors, nurses and midwives per 1,000 people, mainly
because of “brain drain” of trained
personnel to developed countries.

One million extra health workers
are needed to fill this gap on this
continent. Despite the seriousness
of the problem, governments so far
have failed to live up to their commitments to increase spending.

Only two countries have fulfilled a
2001 pledge by African countries to
commit 15% of their national budgets to funding the health sector to meet the Millennium Development Goals. None of the East African countries have met that pledge.

Uganda contributes 9.6%, while
Kenya and Tanzania contribute only
slightly more.

At the forum, governments made
familiar, sweeping promises. “On
our part. “We shall continue to
make efforts towards the 15% goal,” said Uganda’s health minister Dr. Stephen Malinga. “We ask everybody to join.” He offered no
specifics, however, saying the ministry planned to present a proposal to President Yoweri Museveni.

Meanwhile, it is not clear that
donors are ready to step up their
spending to allow for a big increase
in the supply of health workers.

Donors were not well represented at the forum. One exception was Dr. Rajat Gupta, the chairman of the
board of the Global Fund on
HIV/AIDS, Malaria and Tuberculosis, who said: “We have
always committed 23% of our aid to
human resources.”

His announcement surprised some forum participants, who were unaware that there was a portion meant for human resources development The reluctance of donors to step up funding was evident during a recent meeting between the WHO regional director for Africa, Dr Luis Gomes Sambo, and foreign ambassadors in Kampala.

The ambassadors complained that when more funds are injected into the sector, government reneges of its contribution to the health sector, leaving donors to go it alone.

They suggested that poor countries
should clean up their own
houses before asking for more outside money, and they urged WHO to talk with the health and finance ministries about financial efficiency, gains supervision and budget reviews before seeking more funds.

“The current situation on dependency on foreign funding should be revisited until wastage and inefficiency is addressed,” an EU official said, adding, “More projects in the health sector are not a lasting solution.

The corruption index in
Uganda, especially in the health sector, is still very high. I think health comes second after the Police in corruption.”

Participants in last week’s forum
complained not only about the overall level of donor spending on
health. They also said too much
money is spent on specific projects, especially infrastructure projects, rather than the health and human resources in particular. But it is unclear whether donors will be persuaded to change their approach since their own constituents often prefer project-based funding and they tend to view spending on projects as less vulnerable to corruption.

If there are questions about
whether donors will resolve the
health manpower crisis, doubts are
at least as strong about changes in
another institution singled out by
forum participants: The International Monetary Fund (IMF).
It is widely believed that the IMF’s
structural adjustment programmes
of the 1980s helped plunge poor
countries, especially in Africa, into
the health manpower crisis.

IMF dictated reduced government
spending, which led to a reduction
in work forces of poor countries,
effectively blocking recruitment
into the civil service. With the same
poor countries continuing to churn
out qualified professionals, including health workers, the brain drain was almost inevitable, some believe.

But while some forum-goers said
the IMF should ease its restrictive
policies and commit itself to
reverse the situation, it is unclear
how this will happen.

IMF has a long history of resisting
political pressures and urging countries to do the same And since IMF urges countries to set overall spending limits, but does not tell them how to choose between different spending options, a change in its policies at best would lead only indirectly to increases in the health work force.

So the big question left after last
week’s forum is funding. On that
question, the forum offered no
specifics. The forum plans to reconvene to review its impact in two years. Maybe we will have answers then.

The writers are journalists