I would say that the most critical challenge remains that of human resources. There are a few dimensions to this: 1. Increasing supply In many countries, including my own, the supply of health workers (doctors, nurses, pharmacists etc.) has decreased over the last 10-15 years, rather than increase. Governments need to devote more of their financial resources to increase the output of professional health workers. 2. Retention We need to find better ways of retaining health workers. It will not help us to produce more health workers through our medical and nursing schools, but then immediately lose them to lucrative contracts in the developed world. Salaries in the public sector will never match that of the private sector, but there are many non-financial incentives at our disposal that is not being utilised adequately. This would include things such as investing more in the physical infrastructure and equipment at the disposal of health workers. 3. Management Skills There is insufficient focus on building the management capacity of health workers at all levels - we tend to focus on building clinical skills, and forgetting about the essential management skills (core and soft skills). This includes the all-important planning and budgeting skills - too many examples abound of poor service delivery as a result of poor budget planning. 4. Information One of the essentials of scaling up is knowing where you are, and where you need to go, and then knowing if you ge there! Information is key in this. There is insufficient investment in health management information systems - though in many cases there is a lot of effort on data input, but very little on how to use and analyse the data provided so that it could move from data to information! Of course there are many challenges and impediments to scale-up, but these would be some of the must critical, in my mind.

In Southern Africa one of the greatest constraints is "warm bodies" to deliver public health services. A lot has been written on how the demand far outstrips supply. Recruitment and retention of public healthcare service providers is a major challenge for virtually all countries in the region. These countries are attempting to respond by engaging more community based health care workers, who may or may not be fully trained nurses etc. There is little else that can be done at that level, as it appears that the whole world is short of trained nurses. However there is a lot of inefficiency in the management of such skills as exist. This perhaps is where more focus can yield substantial results. Such focus can be achieved by various measures such as introducing business style project management skills in the public service (not just limited to healthcare). This obviously requires different kinds of training and higher levels of committment and support by the employers. Efficiency can also be aided by greater harmonisation between the various donors, the Global Fund included. Unfortunately despite officially subscribing to principles of harmonisation the Global Fund sometimes does the precise opposite, resulting in parallel projects. Despite having worked with the Global Fund for a number of years I cannot understand why its officers bluntly refuse to have combined workplans for activities that are also funded by other donors.

Federal Ministry of Health

Khartoum, Sudan

e.mail: fatihmmalik@hotmail.com

Office: +249 183 776269

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