Background paper to

Global Health Workforce Alliance strategy 2013-2016

Reflections and key issues for the Board to consider

Executive summary

The Global Health Workforce Alliance (the Alliance) was launched in 2006 to respond to

the human resources for health crisis and its lack of attention in the global health

development agenda. It sought to address the shortage, mal-distribution, retention

challenges, migration and inadequate working and living environment of health workers

prevalent in many developing countries. The first years of the Alliance have seen

significant progress across a number of areas relating to health workforce development;

at the same time important gaps persist, against the backdrop of a fast-evolving global

health and development landscape.

Reflecting on its first five years of experience, accomplishments and challenges, taking

into account the evolving global health and development landscape, and considering the

findings and recommendations of the external evaluation recently concluded, this paper

sets out the key issues that the Board is requested to discuss and deliberate on at the

Board retreat scheduled for mid February 2012, and thereafter in the development of a

longer-term strategy for the Alliance.

The Board is called upon to delineate a management response to the evaluation findings,

and a longer-term strategy addressing questions that span its role, vision and mission,

membership, strategic and programmatic aspects (such as relations with HRH focal

points in countries, and with regional entities and networks), governance and

management issues, including structure and functions of the Board and Secretariat, the

relationship with WHO, and resource mobilization Issues.

The ultimate objective is to develop a strategy that will, in the context of a constantly

evolving environment, and considering the accomplishments so far, drive the Alliance

towards making in the future the best possible contribution to addressing the health

workforce crisis.

Key questions for Board's consideration are listed in annex 1 at the end of the document.

The expected outcomes of the retreat include that the Board:

1. develops an initial management response that outlines the broad parameters of its

future vision and mission, and which responds directly to the findings and

recommendations of the external evaluation

2. outlines a process for the development of a longer term strategy for the Alliance

3. disseminates the evaluation report and its response thereto as a basis for renewed

engagement with and support by partners and members.

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Introduction

The Global Health Workforce Alliance (the Alliance) was launched in 2006 to respond to

the human resources for health crisis and its lack of attention in the global health

development agenda. It sought to address the shortage, mal-distribution, retention

challenges, migration and inadequate working and living environment of health workers

prevalent in many developing countries, with the vision that "All people, everywhere

will have access to a skilled, motivated and supported health worker, within a robust

health system". The Alliance is the only global partnership which focuses on human

resources for health (HRH), and its mission is "To advocate and catalyse global and

country actions to resolve the HRH crisis, and to support the achievement of the health-

related MDGs and health for all".

The Alliance undertook a range of initiatives. In March 2008 it convened the First Global

Forum on Human Resources for Health, which resulted in the adoption of the Kampala

Declaration and the Agenda for Global Action (KD-AGA). This framework identified

urgent actions to be undertaken by governments, global leaders, multilateral and

bilateral development partners, civil society, the private sector, health professional

associations and unions. The Alliance developed its 3 year strategy for 2009-2011

("Moving Forward from Kampala") to facilitate and accelerate the operationalization of

the KD-AGA at all levels.

The first years of the Alliance have seen significant progress across a number of areas

relating to health workforce development; at the same time significant gaps persist,

against the backdrop of a fast-evolving global health and development landscape.

The Alliance completed its first five years of existence in 2011. This intermediate

milestone warranted an analysis of its achievements, strengths, weaknesses,

opportunities and threats for the years to come and preparation of its next strategic

plan. As part of the process, the Alliance commissioned an external evaluation, which

has recently been completed.

The purpose of this document is to assist the Board in:

� Framing the discussions at the Board retreat scheduled for February 2012;

� Locating and contextualising the findings of the external evaluation into future

planning;

� Identifying key elements of the future strategic framework for the Alliance in the

period 2013-2016.

The Alliance from 2006 to 2011

The Alliance strategies over 5 years

The Alliance strategic priorities have been outlined clearly from its outset in 2006

through the GHWA Strategic Plan, the GHWA workplan 2006-2008, and the Moving

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Forward from Kampala Strategic Framework for 2009-2011. All these documents have

maintained intact the original vision and mission, and articulated consistently the

Alliance's objectives and thematic priorities, aiming at both accelerating country actions

and addressing global challenges to solve the health workforce crisis through the

functions of advocacy, brokering knowledge and convening partners to promote synergy.

The Alliance Secretariat has worked to operationalize the strategies set by the

Board ,focusing on a catalytic role, providing strategic inputs that trigger action by its

members and other stakeholders on addressing global HRH policy challenges or

mobilizing country leadership. In its first five years of existence the Alliance has led or

significantly contributed to initiatives that have resulted in considerable progress in

driving forward the health workforce agenda at global, regional and country levels.

Key achievements

� At the global level HRH has been mainstreamed into the global health policy and

development discourse and prioritisation through G8 and African Union summits,

international conferences on HIV and maternal, newborn and child health, World

Health Assembly resolutions, the High Level Taskforce on International Financing for

Health Systems, the UN Global Strategy for Women's and Children's Health.

� Stakeholders have been brought together to support policy dialogue around the

development and implementation of sustainable HRH solutions through two global

fora on human resources for health, which resulted in the development of a global

roadmap (the KD-AGA) for all stakeholders involved in addressing the HRH crisis,

numerous thematic task forces, and regional conferences, such as those of the

African Platform on HRH and the Asia Pacific Action Alliance on HRH.

� Widespread advocacy efforts, with partners, such as that on migration which

culminated in 2010 with the adoption of the WHO code of practice (the Code) on

international recruitment of health personnel, an important milestone in tackling

the challenge of the international brain drain.

� Several donor countries, such as the United States of America and Japan, have

started committing to health workforce targets as part of their health development

strategies, or broadened their support to HRH development as part of a health

system strengthening agenda, including also the. Global Fund and GAVI Alliance).

� The Alliance, through its task forces and working groups, has also commissioned or

facilitated the development and dissemination for policy dialogue of ground-

breaking technical reports, tools and knowledge products on the most critical topics

relating to health workforce development, including, among others the planning,

education and financing aspects of a health workforce response, the positive

potential of community-based and mid-level health workers, international migration,

health workforce linkages with the HIV, MNCH and NCD agendas, positive practice

environments to improve health workforce motivation and retention, advocacy for

health workforce development, global progress in the implementation of the KD-

AGA.

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� At the country level the Alliance has refined its support strategy, developing and

rolling out the Country Coordination and Facilitation (CCF) approach, centred around

the principle of creating a collaborative platform at the national level for all relevant

HRH players (across different sectors and different constituencies and stakeholders

groups) to come together to jointly identify health workforce challenges, and

collaborate in the development and implementation of solutions. The CCF roll-out

has generated great demand for support from countries, and has started yielding

results in terms of greater inclusiveness of health workforce coordination and

planning processes, improved quality of HRH situation analyses and development

plans and strategies, and early indications of an acceleration of implementation of

HRH plans and strategies.

Baseline situation in 2009 Progress by end 2011 through CCF

Table 1: results of CCF support to HRH development in countries.

Persisting challenges in the HRH field

Since the mid 2000s, when the HRH crisis was first highlighted, there have been many

signs of increased attention to the health workforce in the health policy arena: the need

to strengthen the health workforce was highlighted as a precondition to improve health

outcomes by nearly every health and development event in the last few years, from G8

and African Union summits to international conferences on AIDS, maternal, newborn

and child health, non-communicable diseases and other health priorities. In 2009 a High

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Level Taskforce on International Financing for Health Systems identified once again the

health workforce as an area requiring critical attention, and called for approximately a

quarter of the additional health investments required to be devoted to workforce

development. More recently the WHO code of practice on international recruitment of

health personnel was adopted; and many low- and middle-income countries pledged to

boost health workforce development in the context of the United Nations Secretary

General Global Strategy for Women’s and Children’s Health.

The dialogue has forged ahead also on a more technical level: new evidence has

emerged on the positive potential of community-based and mid-level health workers;

evidence-based normative guidance is now available on some aspects of task-shifting

and rural retention of health workers; a high-level commission has proposed innovative

ideas regarding the future directions of health professionals’ education (which are being

taken forward through, among others, the MEPI and NEPI initiatives supported by the

US Government).

Moreover, success stories exist of countries that have made significant progress towards

addressing their health workforce challenges. All these developments in the HRH field

are significant steps ahead, and the Alliance can take credit for contributing to several of

them; yet much more remains to be done to achieve the vision of the Alliance and

implement the strategies of the KD-AGA:

• in many countries shortages along with inequitable distribution of health workers

still remain a key challenge. Additionally, supply and training capacities of health

workers remain inadequate in both quantitative and qualitative terms,

• many priority countries have not yet developed or fully implemented their health

workforce strategies due to insufficient technical and financial resources;

• incomplete information on health workers' availability, distribution and

performance hinders effective planning and policy making;

• all these challenges are particularly acute in fragile states and complex emergencies

settings, where progress has been less apparent than in more stable contexts.

Alliance self-assessment and member survey

In its first five years the Alliance has also attempted to learn from its own experiences

and it strove to provide its members, partners and stakeholders with feed-back

opportunities. While these efforts had limitations, key areas emerging from a self-

assessment conducted by the Alliance in 2010 and from a member survey conducted in

2011 included that members and partners:

� value the Alliance as a collaborative mechanism, and see as its key strength its

ability to convene, catalyse action, and get consensus on important policy and

technical HRH issues;

� at the same time they expect greater coordination and stewardship of their

efforts in terms of joint messaging, communications, tools, advocacy targets and

benchmarks;

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� would like to have more venues and mechanisms for regular interacting and

networking, and encourage the Board and Secretariat to more effectively

galvanise the involvement of the wider Alliance membership (now 335 strong) to

address the HRH crisis.

The external evaluation

Rationale and objectives

The Board decided to commission an external evaluation of its first years of operation in

order to allow the Alliance to concentrate on and consolidate further its areas of

strength, address its weaknesses, and provide a high value- added contribution in the

context of a crowded global health landscape. Furthermore, the findings of the

evaluation were meant to feed into the decision on whether the Alliance operations will

be sustained beyond its intended initial ten year life span through to 2016, and, if not,

provide input into an exit strategy.

Accordingly, the Alliance Board in its 10th meeting in June 2010 took the decision to

conduct an external evaluation, and in its 11th meeting in January 2011 agreed to its

terms of reference. The evaluation was conducted to:

� analyse the Alliance's contribution to date,

� reflect on its strengths and weaknesses,

� explore opportunities, identify ways of mitigating threats, and

� make recommendations for its future strategy for the remaining period

mentioned in the MoU with WHO (October 2016).

Key findings

The external evaluation findings are available in full detail in the report produced by

OPM. However, for ease of reference, key findings of the report are summarized below,

and presented according to the areas of enquiry listed in the original TOR (in italics)

� Coherence of strategy with mandate, contributions and added value,

complementarity with and contribution to the work of other key HRH stakeholders;

The Alliance work has been closely aligned with its mandate, but could have better

engaged its members and partners; moreover the Alliance may make further efforts for

redefining and adapting its strategy to a changing environment.

� Results, capacity and credibility acquired to date as: (i) global advocate for greater

political commitment and increased resource mobilization for HRH; (ii)knowledge

broker in HRH; and (iii) convener of collaborative events and platforms,

The Alliance has been successful in all three areas, however more progress would have

been desirable in securing new funding streams for HRH, and greater efforts could have

been made in ensuring the utilisation of the knowledge products it developed through

the task forces it convened.

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� Results in fostering partnerships and promoting consensus for coordinated and

integrated responses to HRH challenges at global, regional and country levels;

The CCF support at country level is effective in promoting coordinated and integrated

HRH responses at national level. However, GHWA needs to strengthen its partnership

strategy and approach at global level.

� Relevance of the work and the strategic functions supported by the Alliance at global,

regional and country levels on national HRH policy making and HRH development;

The Alliance work was highly relevant at all levels; the results of its country work are

however linked to the quality and commitment of national leadership, and dependent

on the availability of catalytic funding to kick-start the early stages of the integrated

HRH response.

� Track record and future prospects in mobilizing financial resources to sustain the core

functions of the Alliance secretariat.

GHWA operations represent good value for money, but are hindered by cumbersome

administrative and financial procedures and processes, which impede effective

management and oversight of resources. Also, the future sustainability of GHWA is

threatened by a shrinking income base and a trend towards earmarked funding, with

negative effects on predictability of income, effectiveness of budget planning and

management, and flexibility required to cover essential Secretariat staff.

The SWOT analysis of the Alliance according to the external evaluation shows that:

� Key strengths include its positive track record and credibility acquired in advocacy

and convening at the global, regional and country levels, organization of global HRH

forums, successful implementation of CCF process, high quality of technical outputs,

the independence of its Board and Secretariat, and the visibility associated with

being hosted by WHO in Geneva;

� Weaknesses include the need for more oversight by the board, the cumbersome

WHO administrative and financial procedures, the lack of a resource mobilization

strategy to take advantage of new opportunities, limited capacity (in terms of both

manpower and resources) to support countries, the perceived lack of full financial

transparency, turn-over of staff, limited results in galvanizing members and partners,

the need to define identity and comparative advantage of GHWA .

� Possible opportunities to exploit are the higher profile of HRH, the possibility to link

with other HRH organizations or UN agencies, the potentially greater role to play

following the restructuring of the WHO HRH department, the need for continued

HRH advocacy, the link with regional platforms and support to HRH focusing on

flagship countries.

� Threats to be considered include the growing competition for resources in a

constrained financial environment, the need to adapt to the changing scenario and a

shared vision on the future strategy.

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Recommendations

The external evaluation provided the following recommendations to the Board:

1. Undertake an urgent review of its own effectiveness in overseeing the Secretariat

2. Engage in a detailed discussion over its future strategy. Key questions within this

area should include:

a. What balance to strike among the three key functions (advocacy, brokering

knowledge, convening) at the three levels where the Alliance works (global,

regional, country)?

b. How to galvanise and better engage members and partners?

c. How best to organize CCF support (breadth vs. depth, adequate staff capacity,

fielding HRH advisers in countries)? `

d. Hosting relationship with WHO (Continue being hosted by WHO, or move out?

Maintaining current partnership model or adopting different one? Stay in

Geneva or more to a lower cost location? Remain independent or integrate

with WHO HRH Department?)

3. Establish a Resource Mobilization Committee to reinforce fund-raising efforts

4. Set up a WHO-GHWA internal working group to review the relationship and

strengthen future collaboration

5. Establish a Finance Committee to oversee the Secretariat's income and expenditure

Limitations of the external evaluation according to the Board TT

The Board TT that oversaw the external evaluation process expressed the view that

OPM have provided a report that has value for the Alliance and that the Alliance should

take good account of their findings as reflective of the diverse views and perceptions

presented to them. The TT, however, also made some observations concerning possible

limitations of the external evaluation:

� The report does not adequately distinguish between subjective perceptions of

interviewees from objective facts, meaning that some assessments may be based on

subjective perceptions rather than on objective facts. The Board must work to

address the causes of these different perceptions as they exist among the

interviewees, but not necessarily take them all as fact.

� The report does not suitably express the level of convergence or divergence of

opinions, the relative weight of how many respondents offered a viewpoint or

interpret information in the context of respondents role vis-à-vis GHWA.

� While the evaluation reflects the diverging viewpoints amongst respondents and

the conflicting information given, they are not brought together as coherently as

they might have, with implications on the proposed way forward.

� The proposal from OPM spoke to validation and triangulation of information

provided by various respondents, but this has not been pursued as much as we had

hoped.

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� The recommendations made in the report on operations and administration

were understandably developed before the recent restructuring of the WHO HRH

department. There are also recommendations relating to changes in the WHO rules

and regulations and its administrative and financial management systems.

� Several programmatic and strategic aspects are raised for the Board to consider.

OPM could have been bolder in offering concrete recommendations on these,

including the balance of work on the three core strategic functions (advocacy;

brokering knowledge and convening) at all three levels (global, regional and

national).

� Conclusions and recommendations could have been strengthened by discussing

their relevance and feasibility in more depth.

� As OPM have indicated and is the case with any evaluation, respondents tend to

emphasise areas in need of improvement.

Key Issues and Questions

Redefining the Alliance future priorities warrants not only an analysis of its

accomplishments and limitations to date, but also of the external environment in which

it operates. And a delineation of its future priorities, in turn, has implications on the

relationship between the Alliance Secretariat and Board with the members, with key

stakeholders that are not members, and on the structure and processes adopted in the

governance and management of the Alliance itself.

The following sections summarize the key issues and questions on these interconnected

aspects. 33 priority questions have been grouped under 10 clusters, which represent the

key issues that the Board is requested to take decisions on.

I. Alliance role in evolving global health landscape and context

While there are persisting gaps in the HRH agenda, the global scenario in which this is

being pursued has undergone rapid changes. The health MDG framework, while

registering varying levels of progress in different areas and in different world regions

and countries, is progressively broadening to a wider paradigm of universal access to a

broader set of health services, including NCD, and taking more explicitly into account

the social determinants of health agenda, deepening the linkages between health and

development at large. Leading development partners are already engaging in a

discussion on the development framework after the MDGs timeline of 2015.

Within this context, many issues on the international agenda compete for attention and

resources, including climate change, food prices, security threats and political changes

sweeping across a whole world region.

The financial and economic crisis has started to directly impact on the HRH field at

several levels; the pace of growth in development assistance for health has slowed, and

the forecast for future years is of stagnating levels of assistance. This has negatively

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impacted on resource availability for different mechanisms for strengthening HRH at all

levels, and in parallel has made development partners even more oriented to results

and cost-effectiveness of the support they provide.

Related to that, in the health sector there is an increasing emphasis in operationalizing

the aid effectiveness principles enshrined in the Paris Declaration, which were

reinforced trough the Accra Agenda for Action, and more recently reinvigorated at the

Busan Forum. In the health sector these have been operationalized in particular through

the International Health Partnership and Related Initiatives at global level, and also

through regional mechanisms, such as the Harmonization for Health in Africa initiative

(the Alliance is engaged in and contributing to both these processes).

In parallel, the increased attention at global level to HRH has drawn to this field an

increasing number of actors; while this undoubtedly represents an opportunity, it also

means that the Alliance needs to be cautious in occupying a mandate and space that

might not be more appropriately filled by other actors and vice-versa.

Ensuring relevance, responsiveness and value added:

In the context of a complex and unfinished HRH agenda, a crowded global health

landscape and against a backdrop of stagnating resources for global health, it is

imperative that the Alliance remains responsive to the changing environment and

external context, while concentrating its efforts on priority actions on which it has a

comparative advantage. The key is for the Board to determine what these are.

The Alliance was launched in 2006 to provide a joint platform for governments,

development partners, international agencies, civil society organizations, academia,

private sector, professional associations and other stakeholders to work together to

address a global crisis in human resources for health and to garner action at global and

country level. Its vision has been that “all people everywhere will have access to a skilled,

motivated and supported health worker, within a robust health system.” Its mission has

been to "advocate and catalyse global and country actions to resolve the human

resources for health crisis, to support the achievement of the health-related millennium

development goals and health for all."

Against this backdrop, in the first hierarchy of priority, there are some core questions

for the Board to answer relating to how the Alliance can strengthen its capacity to

respond to needs and requests expressed by the HRH crisis countries and regional

entities, thereby ensuring continuing relevance and value added in the context of an

evolving scenario.

� Cluster 1: To strengthen responding mechanisms for the needs and requests

from regional networks and HRH crisis countries

1. In the context of what has been achieved and where HRH sits today, what is the

critical unfinished agenda and priority actions required in the lead up to and beyond

the MDG timeline of 2015?

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2. What is the role that the Alliance should occupy in the new HRH agenda and

landscape to better respond to the demands and requests from regional network

and HRH crisis countries?

3. In the evolving HRH agenda, will the Alliance vision and mission still be valid, or

should they be revisited?

II. Galvanizing and mobilizing members, partners, and other non-member HRH

stakeholders:

There is a clear demand from members and partners for clarity of their roles and to

have opportunities to contribute pro-actively to drive forward the HRH agenda. At the

same time, despite a number of regular communications products developed by the

Secretariat which explain the Alliance work, some members and partners tend to view

the Alliance as an agency with all-encompassing responsibilities on HRH, and have what

we have considered unrealistic expectations of what it can and should do.

In addition, there are several significant HRH stakeholders who are not Alliance

members; the Alliance has engaged with them depending on needs and opportunities,

but it is unclear whether the Alliance should encourage a formalization of the relation

with these other HRH stakeholders, and if it should involve them more closely.

� Cluster 2: To consider means and ends for communicating with partners and

members

4. Is the Alliance an organisation whose purpose is to serve its membership and

partners, or one that is there to work with the membership to influence a wider

agenda and set of stakeholders?

5. Is the Alliance comprising the right constituencies, should it be more inclusive, or

more selective in its composition and how should it best engage with non-member

stakeholders?

6. To better engage and communicate with members and partners, what means and

ends should be adopted that can lead to a clearer definition and delineation of

respective roles and responsibilities between the Alliance Board, Secretariat,

members and partners?

7. Should activities organized by the Alliance (such as global fora, online platforms,

corporate communications) aimed at or distributed to only members and partners,

or should the Alliance reach out pro-actively also to key non-member HRH

stakeholders, such as HRH focal points in crisis countries?

Among the HRH stakeholders which are not members of the Alliance, a specific mention

should be made to governments of HRH crisis countries, and in particular to the HRH

focal points within national ministries of health.

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� Cluster 3: To strengthen relationship with focal points in the HRH crisis

countries

8. Should GHWA consider deploying staff to HRH crisis countries, a possibility

mentioned in the external evaluation report?

9. What mechanisms can be put in place to strengthen communication channels with

HRH focal points in crisis countries, and to address their requests?

III. 2013-2016 strategic framework

Based on the answers to the questions above, the Board should strive to identify the

most critical HRH needs and the core contributions that the Alliance is best placed to

perform.

In the last few years, the Alliance focus areas have increasingly been presented and

framed through an 'ABC' framework (Advocacy, Brokering knowledge, Convening), even

though this is not meant to be a distinction with strict boundaries and in reality the

three are closely inter-linked (for example an advocacy target may be pursued by

convening partners through a meeting and brokering knowledge about a certain topic) .

Other functions mentioned in the early strategies are implicitly included in these three

functions (for instance facilitating country actions is achieved through a combination of

all three functions; monitoring the developments in the HRH field is considered part of

the brokering knowledge function, etc). The external evaluation report has also

suggested that the Alliance may consider the option of strengthening its technical

assistance function by fielding HRH experts in the priority countries where it chooses to

work.

As part of its advocacy activities, the Alliance in its earlier years has given greater

priority to the global and regional levels while efforts to engage in national level

advocacy activities are more recent, adopting a mixed focus of targeting both political

and technical audiences. The Alliance has worked to develop an HRH agenda (the KD-

AGA), to mainstream it in high-level political processes (UN High Level Meetings, G8,

AU). It has also engaged in relevant technical fora and in the work promoted by other

agencies (WHA, global health initiatives, bilateral HRH programmes like the Capacity

Plus project supported by the United States Government, among others).

At the global level a core mechanism for convening HRH partners has been the

organization of the first and second global fora on human resources for health, which

have brought together all health workforce constituencies in the development of a joint

health workforce agenda (the KD-AGA) and then in its review and monitoring of

progress three years later.

Some of these advocacy opportunities have been directly led by the Alliance Secretariat,

with speaking engagements and the coordination of conferences, events or dedicated

HRH sessions within other events. Other venues for advocacy have included the

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development and dissemination of relevant materials and communications to relevant

target audiences, activities that have been led by the Secretariat, the Board members,

or the civil society members involved in the Health Workforce Advocacy Initiative.

In parallel, a few global initiatives or platforms have been established on specific HRH

issues (e.g. "CHW Central", on community health workers, the "Hands up", "Frontline

health workers coalition" and "Africa Public Health 15%" campaigns promoted by civil

society organizations, etc)

At the country level, after the early experience of the pathfinder country strategy, which

had limited results, the main vehicle for the Alliance work in the last three years to

achieve the component of its mission that relates to "advocating and catalysing country

actions" has been the Country Coordination and Facilitation process. This new approach

has started delivering initial results, and was acknowledged to be successful also by the

external evaluation.

In order to support its advocacy with a credible knowledge and evidence base, in the

first few years of its existence the Alliance set up and facilitated the work of task forces

established to develop flagship policy and technical reports and tools on priority HRH

areas (such as financing, education, migration, universal access to HIV services, etc). In

addition a number of case studies on different areas of health workforce development

were commissioned or conducted. Following the conclusion of these tasks, and

recognizing the limited demand for this type of products from countries and the high

costs associated with large task forces, the Alliance more recently has not established

new task forces aimed at developing new knowledge products, but rather concentrated

on synthesizing existing knowledge through systematic reviews, on translating

knowledge through the development of more concise policy briefings and reports, or

facilitating the uptake of knowledge through various means, such as online discussions,

web 2.0 technologies, etc Other activities supported by the Alliance have been capacity

building and knowledge dissemination for francophone and lusophone countries.

In defining future priorities of the Alliance, the Board should consider a set of inter-

connected questions exploring the level of emphasis that should be given to its

functions (advocacy, brokering knowledge, convening and to specific activities within

these functions, or indeed different functions or activities that might be identified).

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Figure 1: three possible dimensions of analysis in setting future Alliance priorities

For the broader strategic framework, key questions relate to the identification of areas

of greatest value added through the ABC functions, and any need for revisions of the

current strategic functions.

� Cluster 4: To show typical good examples of ABC as the key current functions of

the Alliance

10. Are the current functions and their current implementation approach the best

possible choice, or are adjustments required? Are the core current functions (ABC)

still relevant, or should any be revised or discontinued? Should the Alliance do

anything more/ different to have greater results?

11. What should be the specific thematic contents within each core function, and to

what extent should the required tasks be commissioned directly by the Secretariat

or advocated to be taken forward by members and partners?

12. Should the Alliance continue and deepen its work on setting the agenda, and

monitoring developments in the HRH field at global level and how should it advance

its approach?

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13. Should new knowledge products be developed and commissioned through Alliance

support and if so, on what subjects; or should efforts be concentrated on translating,

disseminating and facilitating the uptake of existing evidence and new knowledge

and evidence developed by other organizations? How much should the Alliance be a

clearing house for information and HRH information bases?

A key function for the Alliance work has been advocacy, which is pursued through a

number of activities, including the organization of conferences and events.

� Cluster 5: To categorize and prioritize advocacy events and consider

effectiveness

14. Should the advocacy activities continue targeting a political, health service and a

more technical audience, or should they prioritize only one of these target audiences?

15. Should the Alliance Secretariat continue adopting a flexible approach in organizing

advocacy opportunities and events, or should it limit its direct engagement and act

primarily as a clearing house, flagging these opportunities to its members and

partners, and monitoring their contribution? What prioritization should be made

between donor-driven, country-driven and Alliance-driven events?

16. Should the Alliance continue convening periodically (every 2-3 years) a global forum

on HRH? If so, is the current format adequate, or should any changes be made?

In the last few years a number of regional platforms have emerged (some with direct

support from the Alliance) which serve as mechanisms for health workforce or health

systems advocacy and policy dialogue (African Platform for HRH, AAAH, HHA among

others). Opportunities to harness and maximise the potential contributions of these

entities should be exploited.

� Cluster 6: To strengthen relationships with regional networks such as AAAH,

African Platform

17. For the identified core functions, what should be the balance between the work

undertaken at the three levels (global, regional - e.g. through AAAH, African Platform

etc - country)?

Defining expectations of Alliance results at country level in realistic terms.

The evaluation gave a positive assessment of the CCF support to countries; however it

raised questions on the capacity of the Alliance to sustain this approach. A specific

challenge arises when the Board and Secretariat are requested to demonstrate the

impact of their operations on HRH and even more so on service coverage and health

outcomes at the country level. The problem is one of attribution, as the Alliance plays a

niche role targeting root health system determinants, while there are other active HRH

players. As such, Alliance activities cannot be related through a direct and exclusive

attribution link to changes in service coverage and health outcomes, in light of the many

external dependencies and confounding factors. The key questions for consideration are:

16

� Cluster 7: To consider evaluation and effectiveness of CCF

18. In light of the evaluation results on the effectiveness of CCF, should the Alliance

continue facilitating country level work and if so, is the current approach (CCF)

consistent with its mandate or are changes required?

19. Should the Board and Secretariat change the way they frame the Alliance

deliverables, and include outcome and impact measures at country level? If yes,

does it require change of its original mandate?

20. Should the Alliance Board and Secretariat take direct responsibility for producing

and monitoring updated figures on HRH stock, flow, distribution, investment etc, or

just encourage, monitor and report the work of the relevant organizations like WHO,

World Bank etc?

21. How does the GHWA best advocate its value added at country level in the light of

the challenge of lack of HRH data?

IV. Managing the Alliance structures effectively

Structure, size and governance of the Alliance:

The Alliance is a membership-based organization governed by a Board, whose activities

are pursued through the work of a few committees, a Secretariat and time-bound task

forces and working groups. Core governance processes of the Alliance are determined

by the MoU it has with WHO and a Governance Handbook developed thereafter. This

structure has been adapted and revised in the course of the years, and has served the

Alliance well in its first five years, but going forward it is possible that introducing

changes might improve its inclusiveness and/ or effectiveness.

The external evaluation also reported perceptions among some Board members that

the Board and Standing Committee decision making processes are not sufficiently

participatory and transparent, questioned the Board size, the format of Board meetings,

and the effectiveness of the Board in programmatic and financial oversight of the

Secretariat.

So the Board may consider if adjustments are required to the structure and core

governance processes of the Alliance.

� Cluster 8: To consider appropriate function and size of the board and the

secretariat

22. Is there a need for a different composition, size, structure of the Board and its

committees? Should the Board size be reduced and, if so, by how much, and what

should be the revised representation in terms of constituencies?

23. Is there a need to revise and streamline the relationship between the Board and

Secretariat (for instance by dividing the Standing Committee into a Programme and

17

Policy Committee, and in a Finance and Administration Committee? Or any other

combination? Are any changes required in the role, structure and size of the

Secretariat?

24. Should the frequency and format of Board meetings be changed to make it more

effective both in terms of strategic oversight and cost?

25. Are there any improvements required in the relation and communications between

the Board and Standing Committee, and expected role of the secretariat in

facilitating this?

The evaluation report raised concerns about the coordination of the Alliance's

programmatic activities and WHO's; moreover it proposed a review of the hosting

arrangements, floating alternative options ranging from leaving WHO, or to staying in

WHO but changing the type of partnership model, or to integrating more closely with

the WHO HRH department (which has since been downgraded to a unit in a different

department). In parallel, WHO has initiated a process to renegotiate and standardize

the terms for hosting partnerships (this is not exclusive to GHWA, as it applies to 10

other WHO-hosted partnerships).1 In this context key issues include:

� Cluster 9: To consider how to work with WHO and its programmes

26. What defines in a unique and distinctive way the mandate, added value and

complementarity of the Alliance vis-a-vis that of other key HRH stakeholders,

particularly in relation to the collaboration with WHO programmes?

27. Should the Alliance consider and analyse alternative options for hosting

arrangements or continue choosing the option of staying at WHO?

28. If GHWA remains hosted by WHO, should it maintain the current partnership model

(also used by majority of others including PMNCH, HMN etc) or adopt a different

one (such as Stop TB)2

29. Should it explore the pros and cons of the establishment of an "Alliance of

Partnerships" (maintaining individual strategic and programmatic autonomy and

WHO-hosting, but joint administrative functions to reduce costs)?

Mobilizing adequate resources:

Despite considerable evidence of achievements, and of good value for money of its

operations (now attested also by the external evaluation), efforts to mobilize adequate

resources to support the implementation of the Alliance workplans have been only

1 The proposed changes, which are still being discussed internally in WHO, might include the introduction

of a new category of cost recovery expenses, increases in overhead levels up to 20%, and the

establishment of a partnership liability account to be funded by the partnerships. 2 According to the OPM report, the Stop TB model approach is characterized by better integration and

complementarity with the corresponding WHO department; however according to a Lancet article

(Keshavji S et al; Time for zero deaths from Tuberculosis; Lancet 378; 1449-50) Stop TB "has operated

essentially as a subsidiary of WHO’s Tuberculosis Department".

18

partially successful since its inception. In defining the Alliance's future strategy, the

Board should make a realistic forecast of the resource envelope likely to be available,

and adopt a feasible strategy for achieving the short-and mid- term financial targets it

sets.

An additional challenge has been the growing proportion of earmarked funding, which

a. creates a dual governance problem, with the Secretariat accountable at once

for implementing the Board-approved workplan, but at the same time having

to operate within the specific boundaries of the grant agreements with

donors, and

b. makes it difficult to sustain core positions in the Secretariat, as most donors

consider Secretariat staff as an overhead, despite the fact that, in accordance

with the nature of the Alliance operations, most Secretariat staff work to

directly perform its core functions.

At this point, most of the resources required for the 2012 workplan have been mobilized,

even though delivery timings of certain activities may be affected by the timeframe of

pledges and the corresponding cash flow. More importantly, there are only a few firm

and unconditional pledges for 2013 and beyond, with the result that the continuation

and the sustainability of core Secretariat functions and concerned staff positions in 2013

cannot be taken for granted. Understandably several donors preferred to review the

external evaluation findings before making further funding commitments, and many in

any case work on short-term funding cycles of one year only. However, as already

decided by the Board on previous occasions, efforts in resource mobilization need to be

intensified to ensure predictable funding aligned to the strategies and workplans

approved by the Board.

The questions to be considered relate to how the Alliance can re-frame its value

proposition towards the development and marketing of attractive products that can

better support its resource mobilization efforts.

Cluster 10: To create an attractive value proposition for resource mobilization

30. What should be the key messages coming out of the retreat that satisfy and

influence the existing and potential funding partners to sustain and make new

contributions to the Alliance? What role is the Board willing to take upon itself to

ensure this as one of its principal strategic functions?

31. What are attractive products that the Alliance can identify as its deliverables to

support its fund-raising efforts?

32. Once a new strategic framework is agreed, are funding members of the Board

(regular and associate, as well as other donors sitting on the Board as observers)

ready to secure pledges to support the core functions of the Alliance for the next 2

years, based on the findings and the response from the Board on the external

evaluation?

19

33. Based on this, what funding scenarios should the Board plan for, and what are our

best and realistic estimates?

Next steps and processes

The development of the future strategy of the Alliance will take into account the

findings of the external evaluation, but must take into account a wider set of issues of

strategic relevance. At the same time, the external evaluation has posed specific

questions and put forward explicit recommendations that the Board is expected to

examine and respond to.

The Alliance urgently needs a credible management response to the external evaluation,

so as to send a signal of its attention and responsiveness, and reassure members,

partners and donors that it is committed to reflect on the evaluation findings. The

Alliance needs to convey that it will take appropriate action to capitalize on its

strengths and achievements, and to address timely and effectively the shortcomings this

process has highlighted. This needs to be achieved while analysing the evolving HRH

agenda and identifying the position and functions of the Alliance, so that it continue to

play a lead role in the development, response and monitoring of the requite strategies

and actions at various levels and by relevant stakeholders.

At the same time, developing a coherent response to all the questions raised by the

evaluation report and through this background paper (as well as any further ones that

might emerge at the Board retreat), will require time, to ensure that the issues can be

analysed in sufficient depth, and that the relevant partners and members can be

consulted as required.

It is therefore proposed that:

1. An initial management response should be developed to address the findings and

recommendations of the external evaluation. To the extent possible, this response

should also include broad strategic directions on the role and value added of the

Alliance in the future, based on the answers that the Board is able to give in the

course of the retreat to the key questions raised by the evaluation report and

through this background paper (as well as any further ones that might emerge at the

Board retreat).

2. In relation to the development of the new long-term strategic framework for the

Alliance, the Board should outline a process involving all relevant partners and

members leading to the development of the Alliance future strategy for 2013-16, to

unfold over the following 3-4 months, and which, building on the broad directions of

the initial management response, will need to address in sufficient depth all the key

questions raised by the evaluation and through this paper.

To support this process, it is suggested that a selected group of Board members is

nominated, and later joined by leading health workforce experts external to the

20

Alliance, to form an Advisory Group, tasked with developing and presenting an

advanced draft strategy and having it endorsed at the next Board meeting expected

in early summer of 2012.

3. Agree on the mechanism and tools for disseminating the initial management

response to the evaluation and key outcomes of the retreat to all partners and

members, requesting their proactive engagement in future strategy development

process and sustained policy and financial support from development partners in the

short to mid term.

21

Annex 1. Summary of key questions for the Board.

� Cluster 1: To strengthen responding mechanisms for the needs and requests

from regional networks and HRH crisis countries

1. In the context of what has been achieved and where HRH sits today, what is the

critical unfinished agenda and priority actions required in the lead up to and beyond

the MDG timeline of 2015?

2. What is the role that the Alliance should occupy in the new HRH agenda and

landscape to better respond to the demands and requests from regional network

and HRH crisis countries?

3. In the evolving HRH agenda, will the Alliance vision and mission still be valid, or

should they be revisited?

� Cluster 2: To consider means and ends for communicating with partners and

members

4. Is the Alliance an organisation whose purpose is to serve its membership and

partners, or one that is there to work with the membership to influence a wider

agenda and set of stakeholders?

5. Is the Alliance comprising the right constituencies, should it be more inclusive, or

more selective in its composition and how should it best engage with non-member

stakeholders?

6. To better engage and communicate with members and partners, what means and

ends should be adopted that can lead to a clearer definition and delineation of

respective roles and responsibilities between the Alliance Board, Secretariat,

members and partners?

7. Should activities organized by the Alliance (such as global fora, online platforms,

corporate communications) aimed at or distributed to only members and partners,

or should the Alliance reach out pro-actively also to key non-member HRH

stakeholders, such as HRH focal points in crisis countries?

� Cluster 3: To strengthen relationship with focal points in the HRH crisis

countries

8. Should GHWA consider deploying staff to HRH crisis countries, a possibility

mentioned in the external evaluation report?

9. What mechanisms can be put in place to strengthen communication channels with

HRH focal points in crisis countries, and to address their requests?

� Cluster 4: To show typical good examples of ABC as the key current functions of

the Alliance

10. Are the current functions and their current implementation approach the best

possible choice, or are adjustments required? Are the core current functions (ABC)

still relevant, or should any be revised or discontinued? Should the Alliance do

anything more/ different to have greater results?

22

11. What should be the specific thematic contents within each core function, and to

what extent should the required tasks be commissioned directly by the Secretariat

or advocated to be taken forward by members and partners?

12. Should the Alliance continue and deepen its work on setting the agenda, and

monitoring developments in the HRH field at global level and how should it advance

its approach?

13. Should new knowledge products be developed and commissioned through Alliance

support and if so, on what subjects; or should efforts be concentrated on translating,

disseminating and facilitating the uptake of existing evidence and new knowledge

and evidence developed by other organizations? How much should the Alliance be a

clearing house for information and HRH information bases?

� Cluster 5: To categorize and prioritize advocacy events and consider

effectiveness

14. Should the advocacy activities continue targeting a political, health service and a

more technical audience, or should they prioritize only one of these target

audiences?

15. Should the Alliance Secretariat continue adopting a flexible approach in organizing

advocacy opportunities and events, or should it limit its direct engagement and act

primarily as a clearing house, flagging these opportunities to its members and

partners, and monitoring their contribution? What prioritization should be made

between donor-driven, country-driven and Alliance-driven events?

16. Should the Alliance continue convening periodically (every 2-3 years) a global forum

on HRH? If so, is the current format adequate, or should any changes be made?

� Cluster 6: To strengthen relationships with regional networks such as AAAH,

African Platform

17. For the identified core functions, what should be the balance between the work

undertaken at the three levels (global, regional - e.g. through AAAH, African Platform

etc - country)?

� Cluster 7: To consider evaluation and effectiveness of CCF

18. In light of the evaluation results on the effectiveness of CCF, should the Alliance

continue facilitating country level work and if so, is the current approach (CCF)

consistent with its mandate or are changes required?

19. Should the Board and Secretariat change the way they frame the Alliance

deliverables, and include outcome and impact measures at country level? If yes,

does it require change of its original mandate?

20. Should the Alliance Board and Secretariat take direct responsibility for producing

and monitoring updated figures on HRH stock, flow, distribution, investment etc, or

just encourage, monitor and report the work of the relevant organizations like WHO,

World Bank etc?

23

21. How does the GHWA best advocate its value added at country level in the light of

the challenge of lack of HRH data?

� Cluster 8: To consider appropriate function and size of the board and the

secretariat

22. Is there a need for a different composition, size, structure of the Board and its

committees? Should the Board size be reduced and, if so, by how much, and what

should be the revised representation in terms of constituencies?

23. Is there a need to revise and streamline the relationship between the Board and

Secretariat (for instance by dividing the Standing Committee into a Programme and

Policy Committee, and in a Finance and Administration Committee? Or any other

combination? Are any changes required in the role, structure and size of the

Secretariat?

24. Should the frequency and format of Board meetings be changed to make it more

effective both in terms of strategic oversight and cost?

25. Are there any improvements required in the relation and communications between

the Board and Standing Committee, and expected role of the secretariat in

facilitating this?

� Cluster 9: To consider how to work with WHO and its programmes

26. What defines in a unique and distinctive way the mandate, added value and

complementarity of the Alliance vis-a-vis that of other key HRH stakeholders,

particularly in relation to the collaboration with WHO programmes?

27. Should the Alliance consider and analyse alternative options for hosting

arrangements or continue choosing the option of staying at WHO?

28. If GHWA remains hosted by WHO, should it maintain the current partnership model

(also used by majority of others including PMNCH, HMN etc) or adopt a different

one (such as Stop TB)3

29. Should it explore the pros and cons of the establishment of an "Alliance of

Partnerships" (maintaining individual strategic and programmatic autonomy and

WHO-hosting, but joint administrative functions to reduce costs)?

� Cluster 10: To create an attractive value proposition for resource mobilization

30. What should be the key messages coming out of the retreat that satisfy and

influence the existing and potential funding partners to sustain and make new

contributions to the Alliance? What role is the Board willing to take upon itself to

ensure this as one of its principal strategic functions?

3 According to the OPM report, the Stop TB model approach is characterized by better integration and

complementarity with the corresponding WHO department; however according to a Lancet article

(Keshavji S et al; Time for zero deaths from Tuberculosis; Lancet 378; 1449-50) Stop TB "has operated

essentially as a subsidiary of WHO’s Tuberculosis Department".

24

31. What are attractive products that the Alliance can identify as its deliverables to

support its fund-raising efforts?

32. Once a new strategic framework is agreed, are funding members of the Board

(regular and associate, as well as other donors sitting on the Board as observers)

ready to secure pledges to support the core functions of the Alliance for the next 2

years, based on the findings and the response from the Board on the external

evaluation?

33. Based on this, what funding scenarios should the Board plan for, and what are our

best and realistic estimates?