text:
- Research
- Open Access
Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM and PEPFAR-funded HIV-activities
© Cailhol et al.; licensee BioMed Central Ltd. 2013
- Received: 24 June 2013
- Accepted: 25 September 2013
- Published: 25 October 2013
Global Health Initiatives (GHIs), aiming at reducing the impact of specific diseases such as Human Immunodeficiency Virus (HIV), have flourished since 2000. Amongst these, PEPFAR and GFATM have provided a substantial amount of funding to countries affected by HIV, predominantly for delivery of antiretroviral therapy (ARV) and prevention strategies. Since the need for additional human resources for health (HRH) was not initially considered by GHIs, countries, to allow ARV scale-up, implemented short-term HRH strategies, adapted to GHI-funding conditionality. Such strategies differed from one country to another and slowly evolved to long-term HRH policies. The processes and content of HRH policy shifts in 5 countries in Sub-Saharan Africa were examined.
A multi-country study was conducted from 2007 to 2011 in 5 countries (Angola, Burundi, Lesotho, Mozambique and South Africa), to assess the impact of GHIs on the health system, using a mixed methods design. This paper focuses on the impact of GFATM and PEPFAR on HRH policies. Qualitative data consisted of semi-structured interviews undertaken at national and sub-national levels and analysis of secondary data from national reports. Data were analysed in order to extract countries' responses to HRH challenges posed by implementation of HIV-related activities. Common themes across the 5 countries were selected and compared in light of each country context.
In all countries successful ARV roll-out was observed, despite HRH shortages. This was a result of mostly short-term emergency response by GHI-funded Non-Governmental Organizations (NGOs) and to a lesser extent by governments, consisting of using and increasing available HRH for HIV tasks. As challenges and limits of short-term HRH strategies were revealed and HIV became a chronic disease, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives, increase in HRH production and mitigation of internal migration of HRH, sometimes in collaboration with GHIs.
Sustainable HRH strengthening is a complex process, depending mostly on HRH production and retention factors, these factors being country-specific. GHIs could assist in these strategies, provided that they are flexible enough to incorporate country-specific needs in terms of funding, that they coordinate at global-level and minimise conditionality for countries.
- Human resources for health
- Sub-Saharan Africa
- HRH policies
- Global health initiatives
- Health system strengthening
In the early 2000s the international community responded to the Human Immunodeficiency Virus (HIV) pandemic, in addition to re-emerging Tuberculosis (TB) and on-going malaria epidemics, by creating targeted disease-specific funding mechanisms, termed Global Health Initiatives (GHIs). Among those funding for HIV control were the U.S. President's Emergency Plan For AIDS Relief (PEPFAR), the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) and the Multicountry AIDS Program of the World Bank (MAP) [1]. GHIs were defined as "a blueprint for financing, resourcing, coordinating, and/or implementing disease control across at least several countries in more than one region in the world" [2], pp. 74. GFATM and PEPFAR allocated most funds to antiretroviral (ARV) provision [3, 4], which was the most pressing need at country-level at that time, without considering human capacity to deliver these ARVs.
Rapid expansion of HIV programmes in Sub-Saharan Africa (SSA) suddenly revealed the demand for human resources for health (HRH) in a continent already depleted of HRH [5, 6]. HRH demand was not only quantitative, in terms of the scale-up of labour-intensive service-delivery to hundreds of thousands of newly diagnosed patients, but also qualitative, in terms of new skills needed to manage patients with HIV [7]. SSA was faced with a double challenge in relation to HRH, a structural deficit and an acquired shortage. The World Health Organization (WHO) had estimated that 2.3 qualified health workers per 1,000 population – 0.55 physicians and 1.88 nurses/midwives - were the minimum, needed to ensure the delivery of 80% of basic services [5]. This minimum threshold, which varies in relation to the epidemiological profile and the productivity of staff, was far from being achieved in most the countries in SSA at the time GHIs launched their activities.
The distorting effects of HIV funding on countries' health systems, including effects on HRH, were being reported from soon after the launch of GHIs: PEPFAR, by channelling their funding through international implementers and GFATM, by implementing their activities through national non-governmental organizations (NGOs), were responsible for "poaching" staff from an already depleted public sector; in many sites, specific units for HIV patients were created in public facilities around a doctor-centred model of ARV provision, fragmenting the health system; and the skills needed for HIV management were initially developed in standalone programmes and in an uncoordinated fashion, mostly through in-service trainings [8–13].
Such country-level findings, which were often based on key informant interviews at the national level, brought the HRH issue to the attention of global stakeholders and became incorporated into the "health systems strengthening" global agenda. This was evidenced by a number of global initiatives on HRH which multiplied during the last decade: Joint Learning Initiative [14], World health Report [5], Global Health Workforce Alliance, Japanese International Cooperation Agency's commitment to train additional health workers, renewal of interest in Community-Health Workers and Mid-Level Workers, WHO global plan to "treat, train and retain" HRH [15].
At country-level, a number of innovative approaches and new policies, different in nature according to the context, were also developed in response to the aggravated HRH crisis.
This paper provides an analysis of both short-term and long-term HRH responses to implementation of PEPFAR and GFATM funded activities, in 5 countries in SSA. It draws on health policy and system research, an approach born from the necessity to analyse systematically globalized and complex health systems.
A five year multi-country study (2007–2011), funded by the European Commission was conducted in 5 countries in SSA (Angola, Burundi, Lesotho, Mozambique and South Africa), to describe and analyse the effects of GHIs on country health systems. GHIs common to all 5 countries were PEPFAR (except Burundi), MAP (except South Africa) and GFATM. MAP was excluded from the study since not all countries could collect data related to it. The research focused mainly on countries' responses to the increased demand on HRH due to the challenges posed by GHI-funded HIV activities.
The research design was a mixed methods approach, based on a conceptual framework developed to analyse the influence of external aid on countries' health policy and systems. Tools for quantitative and qualitative data collection were jointly developed by the multi-country team, covering the 6 building blocks of the health system [13].
Methods used and details of data collection and analysis in each country
Ethics approval
National and provincial health authorities
National ethics committee
Ethics committee of the Ministry of Health and Social Welfare
National bioethics committee
National, provincial and municipal government research committees, UWC ethics committee
Period of data collection
2009 April-June
2009 February- June
2008 July- 2009 February
2007 March- September; 2008
2008 September -2010 October
2010 May
2011 March- June
2010 February-May
2011 June-September
Language of data collection
French / Kirundi
Portuguese and English
English, Xhosa, Afrikaans, Zulu
Number and type of interviews
National level: Ministry of Health (minister, advisors from the Ministry of Health / PAV-MINSA "immunization program"), and offices of selected Implementing Partners (UNICEF, ONUSIDA, EU, WHO) and NGOs 11 in 2009 1 in 2010
National level: MoH officials (senior managers, HRH/ planning/ programs managers), National AIDS Council secretariat, NGOs representatives, GHIs representatives 27 in 2009 26 in 2011
National level : in-depth key informant interviews with 22 representatives of the government, bilateral and multilateral development agencies and other stakeholders at the national level
National level: 21 in 2008; Ministry of Health (MoH) officials, offices of selected Implementing Partners (WHO, UNAIDS, UNICEF, Irish Aid, PMI/CDC, World Bank, USAID, CDC, DFID) and NGOs (MONASO-network of national NGOs working on AIDS, Malaria Consortium, Health Alliance International
National level: MoH officials, SANAC, international NGO coordinators, international health agencies coordinators 19 in 2008–2009 18 in 2010
Sub-national level: provincial government officers, NGOs, district managers, facility managers 30 in 2011
Sub-national level: provincial government officers, provincial AIDS committee, NGOs, district managers, facility managers and employees 35 in 2009 45 in 2011
Sub-national level: around 60 with provincial and district health directorates, HR managers, NGO managers, individuals in charge of health facilities and services responsible in 2010
Sub-national levels: Provincial and municipal governments, sub-provincial management levels (general manager, HR manager, finance manager) N = 105 from 2009 to 2010
Facility and NGO level: NGO representative, health workers, facility manager N = 144
Type of documents analyzed
National health policy, national programs of Malaria, Tuberculosis and Maternal Health and national and international reports; Published literature and unpublished documents provided by key informants of MINSA, national and international NGOs, Provincial Health Department and Municipal Hospitals.
Policy and planning documents from programs and HRH unit, national health plan, proposals for GHIs
Review of Lesotho's Round 5 Grant Score Cards Grant Performance reports and policy and planning documents from programs and HRH unit, national plan : 10-15
Policy and planning documents from National programs and HR National Directorate, national health plan, grey documents
Policy and planning documents from national department of health, grey documents, proposals for GHIs, draft policies
Quantitative sampling method (sub-national level
3 provinces (2 rural and one urban, in each of which 3 or 4 facilities (NGO, private and public) were selected (14 in 2009 and 12 in 2011)
3 provinces, minimum of 2 districts in each, minimum of two facilities in each district at lowest level providing ART initiation. Rural/urban sampling where possible at each level
Type of quantitative data
HRH national report and national HIV program report for ART patients figures
Survey at facility level (N = 105 in 2009, N = 78 in 2011) to health workers (salary level, incentives, trainings, supervision)
Surveys at facility level for HRH, infrastructures mapping, health information system, and pharmacy information; surveys for NGO mapping and district health services network
Health system trust database for HRH data;
National ART report for ART patients number
Surveys at facility level for HRH number and trainings, surveys for NGO mapping and district health services network
HRH national review and national HIV program report for ART patients figures
Analysis method (software used)
Qualitative data: Thematic analysis - analyzed manually
Qualitative data: Framework analysis using Atlas.ti for
Qualitative data: Framework analysis using Atlas.ti
Qualitative data: Thematic analysis using Nvivo and content analysis
Qualitative data: Thematic analysis both manually and using Atlas.ti
Quantitative data: analyzed using Stata (version 8)
Qualitative data consisted of document review and semi-structured interviews, conducted at different levels of the health system. A first group of respondents was selected according to their relevance to the topic researched and thereafter more were recruited using the snowball technique. A total of 145 interviews at national-level and 419 at sub-national level were conducted in the 5 countries. National-level interviews included key-informant interviews at national and sub-national levels and of development partners (international and local) and government officials.
Interviews were recorded whenever possible, transcribed, translated when needed and coded. Written consent form was obtained prior to each interview. Data in each country were analysed by country teams, constituted of at least 2 researchers, using thematic analysis, done either manually or with software. Annual workshops were conducted to discuss data collection challenges and preliminary findings, to allow triangulation of data and to identify relevant common themes.
Quantitative data consisted of surveys at facility level and secondary data from government information systems. Two categories of HRH in the public sector were considered for quantitative data: medical doctors and professional nurses (basic/intermediate/specialized levels). Other categories, such as pharmacists and community health workers were not homogeneous enough across countries to allow comparisons, or data were missing which precluded cross-country comparisons. Specialist doctors were merged with general medical doctors. Nurse and midwife figures were merged when possible to allow comparisons with the health worker threshold above cited [5].
We provided quantitative data on evolution of numbers of HRH in the public sector (2004–2010) and on ARV roll-out (2004–2009).
This paper first presents and compares background data on each country, followed by the short-term HRH strategies adopted and challenges they posed. The paper then examines countries' transitions from a short-term strategy to long-term HRH policy, as HIV became a chronic disease. Short term strategies were defined as strategies implemented by local stakeholders without a formal regulatory framework, mostly via internal arrangement. Long-term policies were defined as those backed-up by an official authority and a regulatory framework, allowing standardization and sustainability. We finally discuss similarities and differences in strategies and policies across countries, in light of their context and more generally, the HRH strengthening needs and the role of GHIs.
Country contexts
Summary of socio-economic and health related indicators for the 6 countries included in the analysis
South Africa
Significant historic features
Independence 1975
Independence 1962
Independence: 1975
Apartheid 1948-1994
Quarter century of civil war: 1975 - 2002
Cyclic civil wars since 1963
Several military coups with latest handover to democratic government in 1995
Civil war: 1976-1992
Latest: 1993-2006
Population density/km2
Net ODA as% of GNI
GDP in current USD per capita
Public health expenditure, as % of total government expenditure
External resources for health, % of total expenditure for health
OOP expenditure on health, % of total expenditure for health
GINI coefficient (latest available)
58.6 (2000)
33.3 (2006)
52.5 (2003)
47.1 (2003)
67.4 (2006)
Human Development Index ranking 2011 (out of 187 countries)
HIV prevalence 15–49 years old, % (2009)
Number of persons affected by HIV, all ages, 2009
TB incidence, per 100,000 inhabitants, 2010
Number of TB cases detected, 2010
Malaria mortality rate per 100,000 inhabitants, 2008
Under-five mortality rate, per 1,000 live births, 2010
Maternal mortality ratio per 100,000 live births, 2008
GFATM-HIV, cumulative disbursement, as of 2011, millions USD
GFATM-malaria, disbursed, as of 2011, millions USD
GFATM-TB, disbursed, as of 2011, millions USD
PEPFAR, disbursed, as of 2009, millions USD ( + committed 2010)
0 (Not eligible)
MAP1 World Bank, committed, millions USD
51 (with MAP2)
In terms of burden of HIV, Lesotho and South Africa carry the heaviest ones, with, in 2009, an antenatal HIV prevalence of 23.6% and 17.8% respectively. South Africa's larger population meant it had more than 5.5 million HIV-infected people in 2009 and almost half a million cases of TB diagnosed in 2010. Angola and Burundi have the lowest incidence of TB (304 and 129 cases per 100,000 inhabitants respectively in 2010) and HIV prevalence (3.3 and 2% respectively in 2009). Angola, Burundi and Mozambique have the worst indicators for maternal and child health.
With regard to health financing, all governments spent in 2009 from 8 to 13% of their total expenditure on the health sector; this percentage included funding from external sources. The latter represents as much as 72% for Mozambique, 45% in Burundi, and 30% in Lesotho, but only 3 and 2% for Angola and South Africa respectively. If external sources of funding are excluded, government expenditure on health would drop significantly in the 4 first countries, and would then represent less than 7% of total government expenditure.
The health system organization is typically pyramidal in all countries, with a centrally managed district-based system. In Burundi, decision-making remains very centralized at national level, especially budget allocation, since the district health system is very recent. In South Africa, the national level plays a normative role, by drafting policies and allocating funding, while provinces have considerable autonomy and exhibit variation. In Angola, the national level has a normative role and since 2007, municipal health authorities are in charge of district health management (including budget allocation) and planning. In Mozambique and in Lesotho, the decentralization process has been gradual. In Mozambique, provinces gained autonomy, while budget allocation is still centralized. All countries have HRH development policies and plans, but their level of ownership and sophistication varies: South Africa's plan is relatively detailed with projections of HRH until 2025 [16]; Mozambique's is clearly articulated with MDGs and aligned with other policies but lacks funding (National Plan for HRH Development 2008–2015; National Directorate of Human Resources, Ministry of Health, 2008); whereas Burundi launched its first plan only in 2010 [17]; Lesotho's HRH policy is clearly articulated with the Health and Social Welfare Policy (2004) which ensures appropriate supply, and properly trained personnel to meet the needs of the country and also ensures career development.
Numbers of patients on ARV in 2004 and 2009 in the 5 countries
South Africa
2004 (unless otherwise specified)
32,895 (2005)
2009 (unless otherwise specified)
17,500 (2010)
92,773 (2008)
Short term strategies: facing the HIV emergency
Using the pool of available HRH for HIV tasks
Informal or formal task-shifting at facility-level
In all countries except Angola, task-shifting (to less skilled HRH or to lay health workers) occurred at facility-level for HIV clinical management. In South Africa, it was mainly an initiative of international NGOs, first informally by Médecins Sans Frontières (MSF), during the period of HIV denialism in the government [20], followed by GHI-funded NGOs. In Burundi, informal task-shifting was in place in rural areas since before the civil war, because of pre-existing doctors' shortage. However, task-shifting for HIV was not considered initially. More recently, informal initiatives with follow-up of ARV patients by nurses were conducted as pilots, mostly by GFATM-supported NGOs. In Mozambique, the Ministry of Health adopted HIV task-shifting policy early on: formal non-physician clinicians pre-dated the GHIs era and have been further trained for ARV prescription; also, in some rural facilities, nurses were trained to follow-up pre-ARV patients. In Lesotho, task-shifting has always been supported by the government. Nurses in the rural areas have always worked under a written protocol by the district medical officer. This has been extended to HIV/AIDS; nurses have been trained further to initiate ARV treatment in uncomplicated cases.
Challenges: In South Africa, facility-level task-shifting was well accepted locally but remained for a while as scattered pilot projects; and its scale-up was slow, due to a lack of formal process and standardization and an active opposition from professional councils. In Burundi, its uptake was slow, mainly due to some resistance to change from professional bodies as well as from patients, since HIV was considered a complex disease. In Mozambique and Lesotho, where task-shifting was operating historically since before GHIs, its adaptation to include HIV activities was easier.
Allocation of HIV-tasks to specific health workers
In all countries except Angola, specific units for HIV services opened in public facilities. Separation of HIV and non-HIV activities aimed at tighter management of external funding and at training a limited number of HRH. New staff were recruited or staff formerly present were internally redeployed to work in these units. Sometimes one staff member was allocated to HIV-specific tasks within the same unit (e.g. Prevention of Mother-To-Child Transmission -PMTCT- in Maternal and Child Unit).
Challenges: In the short-term, this system allowed implementation of urgent and specific activities but proved unsustainable in the medium-term. Indeed, the numbers of specific HRH needed (clinical as well as administrative) had to be increased exponentially, in parallel to patient numbers. In Mozambique, this stand-alone approach was discontinued in 2007 and HIV services were progressively integrated into the public health sector. Also, except in South Africa, staff within these specific HIV units and in some cases staff allocated to specific HIV tasks within the same unit received supplementary stipends out of GFATM-HIV grant. These practices induced team divisions and tended to undermine mainstreaming of HIV activities.
Increasing the pool of HRH for HIV tasks
Use of retired staff (only in Lesotho)
Retired nurses are used as mentors for PMTCT (by international NGOs) - administration of that program is being moved to the government with local mentors being paid by the government. This strategy has worked because Lesotho was in dire shortage of nurses and utilized available and experienced staff. The biggest challenge was the remuneration while nurses were transferred back to government, since international NGOs paid more than the government.
Stand-alone GHI funded NGOs for HIV-activities
In the case of PEPFAR and GFATM, NGOs delivering HIV-care were either direct or indirect recipients of funding, as disbursement through civil society was a conditionality to get their funding [21, 22]. In all countries, local NGOs were mainly funded by GFATM whereas PEPFAR implementers, who subcontracted to local NGOs, were often U.S.-based. In Burundi and Mozambique, GHI implementing agencies, separate from government, were created. In Burundi, these agencies also funded local NGOs and some of these in turn created HIV-clinics, run independently from governmental institutions. In all countries, GHI-funded NGOs offered higher salaries than the public sector, allowing them to attract more qualified staff. In Burundi, on average, GFATM-funded NGO staff was paid 2 to 3 times more than in the public sector at the time of the survey at facility-level (quantitative data, 2009). In Mozambique, Angola and Lesotho, key informants all reported that PEPFAR implementers provided much higher salaries than GFATM-funded NGOs.
Challenges: All countries faced an internal brain-drain of experienced staff from the public sector to GHI-funded NGOs, due to differences in salary level. In Burundi and Lesotho, migration was also observed from the public sector to the National AIDS Council (NAC) secretariat, where management staff received higher salaries than in the public sector.
HIV staff seconded to facilities - (in South Africa only)
A number of PEPFAR implementers were allowed by government to second staff to public sector HIV clinics, to help them with accreditation and to then hand over the clinic to the facility in which they were located. In one province, GFATM-funded HRH, dedicated to HIV, were placed at facility level and directly managed by the provincial department of health.
Challenges: Clinical staff, paid by PEPFAR implementers and seconded to facilities, were officially paid at the same rate as public sector staff, as a result of internal arrangement, but had higher net incomes as government benefits were not automatically deducted, incurring some resentment from the rest of the staff. The vertical management system of GFATM created confusion and undermined integration. Concerns around whether these seconded staff would be absorbed by the public sector were being raised, as GHI funding began declining.
Informal task-shifting at community-level
In all countries, Community Health Workers (CHWs) existed before the GHI era. In South Africa, CHWs were further recruited and trained, mostly by local NGOs subsidized by GFATM grants, to provide prevention and promotion activities on HIV at community level. In Burundi, Mozambique and Lesotho, new cadres of health workers called "health mediators", "lay counsellors" or "expert-patients" were introduced through funding from GHIs, dedicated exclusively to HIV-related activities [23]. Their training has been provided by GHI-funded NGOs (Lesotho). After their training, they receive short-term contracts with NGOs or hospitals, working under the supervision of NGOs and receiving GHI-funded stipends.
Challenges: In contrast to implementation of task-shifting at facility-level, community-level task-shifting worked well, since it preceded the emergence of the GHIs and did not interfere with existing power and hierarchies amongst professional HRH. However, in Burundi, the curricula of the new cadres of HRH remained 'unofficial' rendering their situation precarious. "Health mediators" were left unpaid for months, due to confusion during the transition between 2 GFATM rounds [24]. The lack of harmonization of trainings amongst different training providers was also a concern in all countries.
HIV as a chronic disease: towards long-term policies
Formalisation of pilot initiatives
Regulatory framework for task-shifting at facility-level
Informal task-shifting was followed by attempts to legitimise expanded professional responsibilities and to standardize practices. In South Africa, the government authorized formal nurse-initiated antiretroviral therapy [25], after the STRETCH (Streamlining Tasks and Roles to Expand Treatment and Care for HIV) trial demonstrated the safety of such a policy [26]. In Burundi in 2008, a ministerial circular authorized nurses to prescribe ARV, though under the supervision of a medical doctor. In Mozambique and Lesotho, where task-shifting pre-dated GHIs, scopes of practice of non-physician clinicians and nurses were officially expanded, with HIV training provided by PEPFAR and international implementing partners (e.g. International Training & Education Centre for Health in Mozambique).
Official creation of new cadre of health workers
Two new cadres of health professionals were officially created in South Africa in 2008 with their job description released by national level through a circular in 2010 [27, 28]. The curriculum of one of them, called clinical associates, includes also HIV management and is partially supported by PEPFAR (funding of HIV/AIDS twinning centre partnerships with US institutions). A middle-level pharmacy cadre, called pharmacists' assistants, has also been created, with some initial resistance from the pharmaceutical bodies. CHWs are recognized in South Africa as having significantly supported ARV roll-out. With the latest, far-reaching reforms in South Africa, known as 'Primary Health Care (PHC) re-engineering', CHWs are now being integrated into so-called "ward-based PHC outreach teams", working under the supervision of nurses and as part of the formal health system [29, 30].
Increasing the overall quantity of HRH
Increase in production
In reaction to overall HRH shortages, all governments made plans to increase local production, sometimes in collaboration with GHIs. In South Africa, nurses' colleges which had been closed down were due to reopen, as part of the new HRH plan, and production by medical schools was due to increase. In Angola, 6 public medical schools were established in 2009 in the provinces, in addition to a pre-existing private school. In Burundi, production of doctors and nurses has increased due to an increase in student intake but also with the creation of private schools, though without a clear linkage between Ministries of Health and Education.
In general, the capacity of pre-service training institutions was already overstretched before the HIV crisis, raising concerns about the quality of graduates. These production increases were sometimes supported by bilateral cooperation: in Lesotho, Irish Aid contributed to training 150 additional nurses in year 2007 while some nurses were recruited from Kenya to work in the remote areas of the country; South Africa has a bilateral agreement with Cuba, to train doctors. PEPFAR supports HRH production since 2011 (in South Africa and Mozambique through Medical Education Partnership Initiative-MEPI- and in Lesotho through Nursing Education Partnership Initiative-NEPI-) [31, 32].
Mitigation of internal migration induced by inequalities in salaries
Anti-poaching agreements
South Africa was the only country where evidence of informal policy adopted by a number of NGOs to stop the poaching of HRH from the public sector was reported (in one province only). In this case, NGOs signed an agreement with provincial authorities to not recruit public sector HRH from the same province. However, it did not prevent poaching from other provinces.
Alignment of NGO salaries to those of public sector
As a result of significant salary inequity between GHI-funded NGOs and the public sector and the subsequent brain-drain, salary harmonisation was attempted in most countries, driven by government or NGOs. In Angola, a formal and mandatory alignment of NGO salaries with those of the public sector was introduced via a decree. As a result, migration of HRH from the public sector to NGOs was partially reversed. In South Africa, alignment occurred through informal and local agreements, with considerable variation between different local governments. However, such salary alignment was only for clinical or monitoring and evaluation M&E staff (and not management level staff): some NGOs proactively enquired about salary levels in the public sector, before setting their own scales upon recruitment. No formal agreement existed at higher level, i.e. provincial or national level. In Mozambique also, in 2006, the Ministry of Health implemented by decree a new policy on salary harmonization between public health sector and NGO staff seconded to public health facilities. As a result, personnel from NGOs are no longer seconded to facilities but give external support to the public health sector. This policy does not go beyond the staff seconded to facilities and as such does not address income inequalities between external NGOs and public health sector employees. In Lesotho, NGOs and other implementing partners still have their own salary scales, independent from the public sector.
Increase in public sector salaries and provision of incentives
In Burundi, the government was unable to enforce alignment of NGOs' salaries to public sector ones, since this latter were outrageously low. In 2010, eventually, industrial action forced an increase in public HRH salary levels, which were aligned to those in neighbouring countries (i.e. Rwanda). Government also implemented a retention policy, including financial incentives to public sector HRH allocated to rural areas. Migration of HRH was then reversed at the same time as GHIs funding stagnated. In Lesotho, although salaries remained low, the government instituted incentives for nurses in the public sector. This was initially meant for nurses who worked with HIV/AIDS patients through the support of donor funding. The allowance was subsequently spread to cover all nurses including those working in hospitals. In Mozambique, the government introduced incentives for senior managers to prevent them from migrating to NGOs in response to evidence of such internal migration [33]. There was a similar policy in Burundi, where the financial top-up came out of GHI or bilateral projects. In South Africa, no evidence of GHI-funded incentives was found.
Redistribution of incentives at facility-level
Burundi and Lesotho, where some specific categories of staff were receiving incentives for TB or HIV activities, piloted a new policy of redistributing those incentives within the entire facility (a decision of NAC in agreement with facility-managers in Burundi, a decision of government in Lesotho). It did not resolve the issue of low salaries since it resulted in a very small amount per person.
Participation of GHIs in performance-based financing (Burundi only)
From 2010, GFATM-HIV started to support the national policy on improving HRH working conditions using a performance-based funding system. GFATM funding served partly to pay for performance related to HIV activities. The policy was mainly donor-driven and donors managed to persuade other significant funders to pool available funding.
This multi-country analysis shows that all 5 countries first adopted short term strategies in reaction to the HIV pandemic and subsequent GHI funding. Those strategies consisted mainly of using the pool of available HRH to deliver on the increased volume of HIV tasks, notably increased numbers on ARVs. These strategies included task-shifting at facility-level, staff attraction and retention using incentives, and creation of stand-alone HIV clinics. To a lesser extent, the pool of HRH was increased through creation and recruitment of new cadres of health workers for HIV, use of retired staff, and secondment of NGO staff to public sector facilities.
On the one hand, these strategies allowed a substantial increase in the number of patients on ARV within a few years and fulfilled the primary objective of HIV programs and funding institutions. However, on the other hand, these strategies generated tensions: between HIV-dedicated and general HRH staff, by creating parallel channels of management and inequities in incomes. While HIV-dedicated HRH positions were better paid, these positions were not sustainable and tasks were not always clearly defined.
Eventually, countries favoured certain short-term HRH strategies over others, with support from GHIs and other donors.
Short-term strategies: implemented according to GHIs' common funding conditionality and countries' specific contexts
In all countries, funding from GHIs provided a substantial amount of money, usually with a clear conditionality related to quantitative targets achievement, to kick start the disbursement of the next financial tranche [21]. This mechanism of funding was new, placing significant pressure on country systems and accountability. This pressure contributed to the creation of parallel HIV units to enable M&E reporting to GHIs, and to allow targets to be reached quickly [9]. The necessity to quickly reach such targets, led to recruitment and training of HRH, who were retained using incentives. Recruitment however occurred only in a limited number, due to the restricted funding amount. The creation of vertical programs was seen to be justified by the sense of emergency, generated by a series of high level global policy meetings around 2001–2002 in response to the growing HIV epidemic in SSA. It probably also served to demonstrate the effectiveness of certain types of funding over others, thus fuelling pre-existing competition between agencies at global level [34]. In addition to the workload added by HIV care, the combination of preventative and curative care that GHIs funding was meant to deliver was new to public sector facilities, and GHIs proposals were an open call to NGOs and civil society participation [21]. This partly explains the extensive use of NGOs (local and international) as short-term strategies to overcome the HRH crisis, either by seconding their staff to facilities, or by creating stand-alone NGOs for HIV care. In addition to these explanations above, which influenced certain types of short-term HRH strategies over more long-term ones, each country reflected its specificity, according to its historical and political background.
In South Africa, the health system in the pre-GHI era was already sufficiently organized relatively to the 4 other countries. On the one hand, this allowed secondment of NGO staff to public sector facilities, according to a pre-defined agreement. On the other hand, the very hierarchical and managerial functioning of the South African health system did not immediately allow a clear task-shifting model to be implemented at facility-level. NGOs were the most innovative in this domain, testing several models of care in different facilities.
In Burundi, Lesotho and Mozambique, a parallel implementing agency, separate from the Ministry of Health, was created to manage funding from GHIs. Furthermore in Burundi, a separate Ministry of HIV/AIDS was created. Such separation between health and so-called HIV sectors, while facilitating the daily management in the short-term, created inequities in treatment between HIV-dedicated and general staff. Also in these 3 countries, the use of CHWs was well accepted, since rural areas have relied on them for decades, especially during times of civil war. In Angola, no task-shifting was employed at facility level, nor were HIV units created, possibly related to a relatively low prevalence of HIV in the country.
As challenges and limits of short-term HRH strategies were revealed, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives (new cadre of health workers, task-shifting), increase in HRH production, and mitigation of internal migration of HRH, by increasing public HRH salaries or by imposing salary alignment on NGOs.
The move of countries towards Health System Strengthening (HSS), including HRH strengthening
Content of HRH strengthening policy differed, according to, inter alia, countries' financial and political resources and to their resultant degree of dependence on external donors. Thus, South Africa and Angola could more easily create new cadres of health workers since these governments had sufficient funds to devote to indigenous training institutions and to increase production of HRH. Some countries, such as Burundi, did not have the negotiation space to impose a code of conduct on NGOs (i.e. to set a salary scale). Such policy space depends significantly on the extent of reliance on external donors, including NGOs. Burundi preferred to increase public sector salaries instead, which was already a pressing issue. South Africa managed to impose an anti-poaching agreement on NGOs and both Angola and South Africa managed to force NGOs to align their salaries with public sector salaries. The Mozambique government forced to align salaries of NGO staff seconded to public sector facilities with those in the public sector, but did not have any control over salaries of NGO staff per se.
Countries also implemented HRH strengthening policies, independently of GHIs: in Angola, South Africa and Burundi, governments started to sign bilateral agreements with countries which have a surplus of HRH, such as Cuba (for South Africa, though this pre-dated GHIs), China and Egypt (Burundi). In all countries except Angola, governments implemented incentive schemes for rural areas and sometimes retention schemes for undersubscribed specialties, independently of GHIs. In South Africa, the national department of health introduced increased remuneration to some categories of public sector HRH to reduce external or internal migration ('occupational specific dispensation'). Medical interns are also required to perform community service for 2 years in rural areas. In Mozambique, health workers working in remote rural areas are allocated an "isolation subsidy" which increases with remoteness of the placement. In Lesotho, to increase rural coverage, public sector nurses are mandatorily sent to rural areas for a period of 2 years (national policy in place since before GHIs). Also, some faith-based organizations, mostly located in rural areas, provided lower salaries than government and hence are being subsidized by government. The government, with donor support, recruited nurses from Kenya and Zimbabwe to work in some of the health facilities in the remote areas. Since 2006, in Burundi, medical doctors need to spend a 2-year mandatory period in the public sector, mostly in rural areas, if they wish to specialise.
What were the drivers for changes in GHI policies?
GHIs and governments increased their collaboration and GHIs reshuffled their scope of activities in order to fit the HRH strategies at country-level, following the Paris declaration and acknowledging the need for aid effectiveness and increased coordination. GHIs started to take HRH pre-service trainings into consideration, although production was not initially their concern. PEPFAR for instance launched the MEPI and NEPI in 2010, two programs aiming at strengthening pre-service training of HRH [35].
Whether these changes were induced by repeated criticisms of GHI's targets which were predominantly aligned to short-term objectives, such as short-courses and in-service trainings, has been a subject of debate [36]. Attribution to one or other cause is not possible and these changes were probably a result of a mixture of events and influences: GHIs were evaluated through a pre-set mechanism (i.e. 5-year GFATM evaluations for GFATM) [21], and further analysed via independent or commissioned research; many of them emphasized the fragmenting effects GHIs were having on the health system and in particular on HRH [9, 11, 13, 37–39]; external advocacy towards more focus on HSS and against "AIDS exceptionalism" also grew, through conferences and publications; a global HSS debate was complemented by a focus on long-term HRH production [40].
As countries' responses to HRH challenges were reported to GHIs, some of these, such as GFATM and Global Alliance for Vaccines and Immunization (GAVI), with a participative approach, allowed criticisms to be partly addressed in a timely manner: GFATM in 2005 introduced a HSS section to their funding application and GAVI-HSS was launched in 2006 in pilot countries [41]. Other GHIs, such as PEPFAR, more rigid in its functioning and administration, also took into account such criticisms, but at a slower pace and in a more contained way [22, 42]. The slow shift to more sustainable, indigenous responses towards HSS and especially HRH strengthening seems therefore a result of a dialectical relationship between GHI-driven initiatives and country responses, while the shift has also been impelled by other objective changes (e.g. availability of generic drugs). Reduction in global funding is also certainly forcing countries and GHIs to invest more in long-term action, such as pre-service training, better coordination of training, collaboration across sectors through partnerships or across programs (TB-HIV, HIV-reproductive health) and equity in salaries.
HSS and HRH strengthening: what's in the name?
While GHIs should be commended on their genuine efforts to improve countries' health system, whether these HSS plans are really strengthening or just supporting the health system is a matter of debate [43]. Also, an ideological struggle seems to have arisen around whether GHIs have de facto strengthened health systems or had the opposite effect [44–48]. Answers to these questions will influence future HSS directions for GHIs and countries and caution is needed in interpreting them, since answers might differ depending on who the assessor is and what meaning is given to "HSS". Suggestions for a new orientation of GHIs have started to emerge based on accumulated country-based experience and other complex factors [49].
GFATM and GAVI have both included in their funding programs a stream for HSS, but results have been mixed: GFATM interrupted its HSS program a year after its launch, due possibly to a lack of clear definition of HSS [50]. No clear objective for HSS has been set and each program has been left to strengthen its own system. GAVI-HSS programs have not taken into account sustainability: for example in Burundi, the GAVI-HSS funds were used inter alia to pay for fuel and salaries for drivers, in order to transport pregnant women to referral hospitals. Also, initially, an item for HRH capacity strengthening existed in all GFATM proposals, but these were mainly interpreted as in-service training by recipients or used to hire extra staff, without a clear sustainability plan. Some of these HRH are now left without a secure position since GHI funding has shrunk.
Similarly, the MEPI and NEPI are projected as examples of PEPFAR platforms for strengthening the sustainability of HRH in the countries [22] though the majority of funding is still clearly earmarked for expanding HIV management and HIV research capacity [31]. The non-coordination between GHIs at global level, impacting negatively coordination at country level, has also emerged as a common feature to all countries, in our example of HRH strategies. In an attempt to respond in a coordinated way to health system challenges, a project to develop a joint HSS funding platform between the World Bank, GAVI and GFATM was launched in 2009 [51, 52]. However, the project has stalled, showing, inter alia, the extent to which an agreement on HSS objectives and visions is difficult to obtain [53].
Our study has some limitations.
Qualitative data were collected in a cross-sectional,manner with different time-periods (Table 1), rising issue of temporal bias while comparing findings.
Quantitative data proved difficult or impossible to compare, since HRH categories were not the same across countries, and data were not consistently available or complete for the same time periods. The numbers of HRH specific to HIV were not available; nor were the distribution of HRH according to NGOs/private/public sector. Hence, quantitative data were provided solely for an illustrative purpose and do not serve as a basis for a rigorous statistical comparison. Information on non-response rates to requests for interviews was not available consistently across the 5 countries and was therefore not presented. This could have contributed to an ascertainment bias.
Some important institutions such as professional councils were not interviewed at first, or, even when solicited, did not reply (Health Professionals Council in South Africa). This constitutes a limitation given the role that professional councils play in HRH policies.
Particular policies adopted to counteract a specific effect induced by GHIs were difficult to distinguish from more general policies adopted by the government to address the overall HRH crisis, which pre-dated GHIs.
Finally, given the open nature of the health system, attribution of changes to the influence of GHIs or activists/researchers or countries is an impossible task (and probably not useful). The truth probably lies somewhere between these different interpretations, where stream of influences mix with experiences and beliefs and create a general direction that actors tend to follow and refine through compromise and consensus. This last point refers directly to the inherent complexity of the field of health policy and system research, constantly influenced by political and social dynamics [54].
Despite these limitations, we believe that this study provides a unique insight into the complex and slow process of policy shift which has occurred in five countries, between 2007 and 2011, using the example of HRH policies and their evolution in response to GHIs and related HIV activities. Collectively, the findings point to some consistent patterns and effects of GHIs on HRH policies and the workforce, as well as some context-specific differences, across these five southern African countries.
This cross-country paper has shown the differences in countries' strategies, in response to a common challenge, illustrating the extent to which factors inherent to countries are influential. These findings provide further evidence of the importance of country led policies in HSS [55]. Countries are best positioned to assume responsibility on how to best use the global funding available for the purpose of HSS. HSS proposals should be scrutinized carefully according to each country's context and broader factors, since the "one size fits all" strategy has proven its inefficiency and sometimes its counter-effectiveness in the long-run. A preliminary impact assessment might be one mechanism, to anticipate any unexpected outcome due to a particular type of funding/policies on the general health system [56]. There is also an urgent need to better define what exactly "health system strengthening" means for donors, for recipients, but most importantly for health system users, i.e. for patients.
This study was funded by a European Commission project "GHIs in Africa" (grant number INCO-CT-2006-032371).
We thank Ms Renata Mares for her useful comments to the paper during its design.
Authors' Affiliations
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I finished the leftover turkey yesterday, which means today is Christmas. Tomorrow, barring anything unforeseen, will also be Christmas, as will each remaining day of 2014. Fine by me.
I used to dislike Christmas, because I'm not religiously inclined, and don't have any desire to give or receive tons of plastic, woolen, or hickory-smoked bullshit, but my primary gripe—that the Christmas season is way too long—has been rendered obsolete by the new reality that every damn day is a holiday of some sort. Thanksgiving has long since become Thanksgiving Weekend, which this year spanned a couple of entire Tuesdays, with several double-dip days devoted to a certain kind of shopping.
So if every day is a holiday, then it might as well be Christmas forever, because December 25 th is the day when the fewest people have to work. Also, it should be Christmas even more often than it already is because my wife likes it, and she's a nice person who isn't into mindless materialism or religion any more than I am and still makes a convincing case that Christmas is a nice time, what with the Nutcracker and the lights and the days off work and, I'll add, the beer.
Of course, these days there are beers not just for every season, but also for every micro-season. There are late-winter white IPAs and mid-fall fresh-hop ales, and I have to imagine some enterprising packager is going to forcibly enroll us all in the Radler of the Month Club next summer. But Christmas beers and winter warmers have been around forever, and they provide a welcome respite from the hop madness that overtakes the modern brewing industry the other 10 months of the year.
There's no real definition of a Christmas or winter beer, but they tend to be sweet and malty, usually boozy and sometimes spicy, and they provide a very festive way to justify the first leg of a sensitive soul's necessary season-long bender. One of my favorites is Tröegs Mad Elf, an 11-percent-ABV Belgian strong dark ale brewed with cherries and honey.
Mad Elf has a deep ruby color and a nice off-white head of mixed-sized bubbles. Cherries and Belgian yeast—heavy on the cloves—dominate the aroma, with chocolate malt and honey in the background. The first sip brings to mind chocolate-covered cherries, with a light current of banana growing stronger from beginning to end. The pilsner malt and Saaz hops add a bit of pepper on the finish, drying things out and bringing this back down to earth and firmly ensconsing it in the "yup, this is a real beer" category, while the well-crafted mishmash of flavors keeps the high booze content well hidden throughout.
Tröegs is my favorite Pennsylvania brewery, and while I can't declare this to be the finest Christmas beer with a few weeks of research left to go, I can confidently state that a 750-ml bottle of Mad Elf is an excellent way to turn $9 into a firm but gentle buzz.
This is Drunkspin Daily, the Concourse's adequate source for booze news, reviews, and bullshit. We'll be highlighting a beer a day in this space; please leave suggestions below.
Will Gordon loves life and tolerates dissent. He lives in Cambridge, Mass., and some of his closest friends have met Certified Cicerones. Find him on Twitter @WillGordonAgain. Image by Jim Cooke.
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OPENS: SATURDAY, OCTOBER 20 at 8pm and runs through SUNDAY, NOVEMBER 11, 2018
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Tickets range from $20 – $84 (Prices subject to change)
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This rate can vary widely depending on the number of people in the class, the length of the class, the distance I need to travel, and your budget. My rates are very reasonable and negotiable.
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My rates are extremely reasonable. Personal trainers usually charge anywhere between $60 to $100 per session and counseling sessions with a health care professional vary widely and can be quite expensive. As of January, 2012, my rates are $40 per training session and $20 per counseling session. The weekly counseling session can be conducted in my home, in the convenience of your home or using Skype on your computer - I will show you how. The training sessions can be done at either a health club or in your home. You must either become a member of one of the clubs that I have a working relationship with or be willing to invest in a weight bench and a set of dumbbells. The suggested, minimum commitment in order to show significant results is 8 weeks - one nutritional counseling session and two training sessions per week, but if you would like additional training and/or coaching sessions I will work with you as long as you want to.
Your initial appointment is complimentary which will give you a chance to see what I have to offer and decide if it's something that you want to take advantage of. If you decide to work with me, I will accept a deposit which will cover your first two weeks. After that, counseling and training sessions are paid a week in advance with a refund or credit provision for any session cancelled 24 or more hours in advance. When I receive your deposit I will give you some assessment forms and a dietary record form and we will schedule a nutritional counseling and a training appointment.


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Forklift manufacturer Crown Equipment extends its global environmental commitment with the release of its 2010 Crown ecologic Report highlighting the company's sustainability initiatives and accomplishments around the world.
Crown Equipment Corporation is a world-leading manufacturer of forklift trucks.
The 2010 ecologic report communicates the company's commitment to sustainable design and business operations including accomplishments in the past year, initiatives in progress, and awards and recognition.
This year's report includes two new sections detailing sustainable design as well as safety and health programs.
Key ecological initiatives by Crown Equipment:
- Retrieved and recycled waste materials in Australia
- Recycled 1192 tons of scrap metal, over 700 m³ of cardboard, 740 tons of lead batteries, and over 50m³ of plastic materials in 2009-2010
- Crown Australia uses LPG-powered company cars that will save a further 58 tons of carbon per year
- Crown's electronics manufacturing plant in New Bremen, Ohio, USA achieved zero landfill status, becoming the 2nd Crown facility to reuse or recycle all of its waste
Crown President Jim Dicke III comments that Crown ecologic represents the synergies that exist between environmental responsibility and sound business management.
Buyers of Crown lift trucks can be confident they have selected a truck that is manufactured with minimal waste and designed for exceptional energy efficiency and long life.
Additionally, Crown and Walmart Canada collaborated on a project to equip the retail giant's new perishable distribution centre with a fleet of Crown PC 4500 lift trucks incorporating hydrogen fuel cells.
The Crown PC 4500 lift truck was one of the earliest pallet trucks to be designed specifically for fuel cells in an effort to ensure there was no negative impact on safety, efficiency and performance. Crown has qualified 20 of its electric lift trucks to operate with fuel cells.
Crown's 2010 ecologic program also included these accomplishments:
- All facilities in all regions deployed full load-consolidation programs, identified new recycling streams, and added recycling symbols to all applicable new and existing parts
- Crown Mexico earned a 'Clean Industry Certification' from the Mexican Environmental Authority Procuradoría Federal de Protección al Ambiente
- Crown Roding, Germany reduced packaging materials throughout its operations and started using shredded cardboard for parts shipping
- Proactively worked with suppliers to deliver most components to the assembly line in reusable containers
- Crown China upgraded facilities to maximise energy use through installation of a variable frequency drive controlled compressor that matches air conditioning units' running speed with demand


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Histopathology / Cytopathology
(02) 9855 5150
Special interests: Bone and soft tissue
pathology, immunohistochemistry, gastrointestinal and breast
Dr Alison Cheah graduated from the University of New South Wales
in 2003. She trained in anatomical pathology at Cleveland Clinic in
Cleveland, Ohio, in the United States, where she also completed her
Fellowship in bone and soft tissue pathology in 2013. Having
completed that Fellowship, she returned to Australia and obtained
her FRCPA in 2015. Dr Cheah has broad interests in surgical
pathology, with special interests in bone and soft tissue
pathology, gastrointestinal and breast pathology. She has presented
and published a number of papers on soft tissue tumours and is
currently involved in several research projects. Dr Cheah enjoys
teaching and is involved in a variety of teaching activities for
pathology registrars, medical students and laboratory staff.


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Gather your friends for a fun night of crafting, design, or organizing. As a thank you for hosting a party, you will get a one-on-one design or organizing consultation with me for free! Guests pay a small fee to take part in one of the unique workshops offered. For the Make-It-Take-It home decor crafting classes, guests will take home their project at the end of the night. For the design and organizing workshops, guests will each receive a party favor as a thank you for attending.
Interested in hosting a Design + Wine Night Workshop in your home, or are you a business that would like to hold a design class in your space? Contact me today for more details and to set a date!
Make-It-Take-It Home Decor Crafts:
Succulent or Silk Flower Shadow Box
Picture Frame Memo Boards
Rock Salt Candle Holder
(… and more crafting classes still to come!)
Design and Organizing Topics:
Design Basics – My top 10 design tips, based on the most commonly asked questions by my clients
The Color Class – How to choose the right colors for your space using color psychology and color coordination
Wow Your Party Guests – Great for the holidays and summer soirees, this class offers tips on putting together the perfect party, from decorating to place settings to creating a custom cocktail
10 Steps to a Better Kitchen – A step by step guide on how to get your kitchen organized and maximize efficiency
Fix Your Family Calendar – Family schedule way too hectic? This time organization class will help you schedule your families activities, chores, and family fun nights.
De-Clutter the Kid's Corner – Have that one room in your home that's been taken over by the kids? This class will give you 10 tips on how to take your kid's space from messy to functional and fun (and give you tips on how to get the kids to keep it clean!)
The Efficient Home Office – This class offers tips on how to create a home office space for bill paying and homework, how to get it organized, and how to keep it that way!


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Staying in a position to perform backups video games on PS2 can be convenient and typically very expense conserving. Thanks to the a variety of disc examining configurations of diverse types of the PS2 program, discs are far more prone to scratches than on any other console. You can stay away from owning to re-obtain video games by understanding how to perform backup PS2 video games.
In this tutorial, you will study the very effortless system of how to perform back up video games on PS2.
PS2 players used to use a modchip or swap magic or cogswap to backup video games and perform them. These procedures are not only much too intricate for normal folks, but also not protected to use. If there is anything completely wrong in the procedure of putting in, they may entirely wipe out their expensive PS2 and the video games. Also, just one really should devote a further couple bucks to invite expert to do the modification, and some money on the modchip or other supplies. Which is all additional charges, which could be saved by employing a game copying software package. With the support of a excellent game copying software package, just one can make one:one backup copies of his most loved PS2 video games, just the very same as the original. So the backup is playable on PS2.
Certainly they contained the boot sequence as a part of the software package. This sequence was embedded deep in these kinds of plan and heavily encrypted and empower you to burn up it onto normal disks. The software package is alternatively simplistic as we did not really feel we wanted a complex interface. It will work pretty significantly like a normal CD/DVD burner. You can copy/Burn ISO files onto the disk and it mechanically …


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Longchamp's Le Pliage is one of the fashion world's most successful products, a cultural icon across the globe. But managing the low priced, nylon handbag is challenging as Longchamp tries to move its brand upmarket into higher priced, luxury leather goods. Senior Lecturer Jill Avery discusses the balancing act of cherishing the heritage of an established brand against the need to look forward and grow in the face of a rapidly changing industry.
Pal's Sudden Service has developed a unique operating model and organizational culture in the fast food restaurant business. With an emphasis on process control, zero errors, and extensive employee training and engagement, Pal's has been able to achieve excellent performance in an extremely competitive industry. Professor Gary Pisano discusses the company's strategic challenge of deciding how much to grow and whether its organization model will scale.


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In the Western world, yoga became popular as a system of physical exercise. Yoga in Indian traditions, however, is more than physical exercise, it has a meditative and spiritual core.
There is a broad variety of Yoga schools, practices, and goals in Hinduism and Buddhism.
Yoga has five principal meanings:
- Yoga, as a disciplined method for attaining a goal;
- Yoga, as techniques of controlling the body and the mind;
- Yoga, as a name of one of the schools or systems of philosophy (darśana);
- Yoga, in connection with other words, such as "hatha-, mantra-, and laya-," referring to traditions specialising in particular techniques of yoga;
- Yoga, as the goal of Yoga practice.
MeditationDo you find yourself branching out from that one thought in a hundred different directions?Let the thoughts arise.Observe them and let them be, without delving into them. It's like watching carspass by on the street.Meditation can relax your body and calm your mind, but only if you allow it. With practice, the explosion of thoughts will dissipate as you clear your mind and let go of the chaos.Regardless of the meditation techniques you choose, stick with it andyou'll soon benefit both physically and mentally!
Mindfulness is the psychological process of bringing one's attention to the external and internal experiences occurring in the present moment, which can be developed through the practice of meditation and other training.
As one practices regularly, it becomes easier to keep the attention focused on breathing. Eventually awareness of the breath can be extended into awareness of thoughts, feelings and actions.
When considering aspects such as sense of responsibility, authenticity, compassion, self-acceptance and character, mindfulness meditation contributes to a more coherent and healthy sense of self and identity. Research on how mindfulness meditation works suggests that it exerts its effects in components of attention regulation, body awareness and emotional regulation.
"Prana" is the vital energy that pervades the cosmos and sustains the nervous and cellular tissues of the body. "Ayama" is rhythm or flow.
Sit up straight. If you can't sit in the lotus position (cross-legged), sit with your legs folded under you like the Japanese. Keep your spine straight
Breathe in. Inhale deeply through one nostril while you keep the other closed with your fingers.
Hold it. Hold your breath for 10 seconds.
Breathe out. Exhale the air through the other nostril, which you have kept closed with your finger, and then inhale again through that nostril.
Yoga and meditation help you achieve
inner peace and clarity
Usually we find it difficult to control our mind. It seems as if our mind is like a balloon in the wind – blown here and there by external circumstances. If things go well, our mind is happy, but if they go badly, it immediately becomes unhappy.
By training in meditation, we create an inner space and clarity that enables us to control our mind regardless of the external circumstances. Gradually we develop mental equilibrium, a balanced mind that is happy all the time, rather than an unbalanced mind that oscillates between the extremes of excitement and despondency.
Eventually, we will be able to stay happy all the time, even in the most difficult circumstances.
Meditation & Mindfulness
How to Meditate
The Benefits of Meditation
What is meditation?
Meditation is not about concentrating, focusing, visualization or trying to stop your thoughts. It is about letting go and surrending to the inner silence. Meditation is not easy to master, but persevere and it may turn out to be the most rewarding thing you ever do. It takes practice to achieve a peaceful state of being, and there is no question that patience is a key component of our progress through meditation.
Beginning the day in a state of peace and silence makes the whole day go better. You will find it very easy to go into thoughtlessness and feel the vibrations if you get up early in the morning and meditate for 5 to 10 minutes. You will find most of your chakras will clear out in the morning meditation.
With the hectic pace and demands of modern life, many people feel stressed and over-worked. It often feels like there is just not enough time in the day to get everything done. Our stress and tiredness make us unhappy, impatient and frustrated. It can even affect our health. We are often so busy we feel there is no time to stop and meditate! But meditation actually gives you more time by making your mind calmer and more focused. A simple ten or fifteen minute breathing meditation as explained below can help you to overcome your stress and find some inner peace and balance.
Reflexion can also help us to understand our own mind. We can learn how to transform our mind from negative to positive, from disturbed to peaceful, from unhappy to happy. Overcoming negative minds and cultivating constructive thoughts is the purpose of the transforming meditations found in the Buddhist tradition. This is a profound spiritual practice you can enjoy throughout the day, not just while seated in meditation.
On this website you can learn the basics of Buddhist and some other types of meditation. A few books are mentioned that will help you to deepen your understanding if you wish to explore further. Anyone can benefit from the meditations given here, Buddhist or not. We hope that you find this website useful and that you learn to enjoy the inner peace that comes from self reflexion.
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Microsoft Outlook consist two data file such as PST and OST where PST file is used for POP3, IMAP and web based mail where OST is used for MS Exchange account and in an offline mode. Also, it also works in the online mode and automatically performs the task when server is connected with MS Outlook. OST file stored Outlook data items such as Contacts, Messages, Tasks, Calendar, Notes, Journals, RSS Feeds, etc. In this blog, I have shared about some important points about OST file and manual solution to repair the OST files.
Continue reading How to Repair MS Outlook OST File Manually?


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Why solar wind is rhombic-shaped
Temperature and energy equipartition in cosmic plasmas explained
RUB researchers report in Physical Review Letters
Temperatures and pressures in the cosmic plasma
The solar wind consists of charged particles and is permeated by a magnetic field. In the analysis of this plasma, researchers investigate two types of pressure: the magnetic pressure describes the tendency of the magnetic field lines to repel each other, the kinetic pressure results from the momentum of the particles. The ratio of kinetic to magnetic pressure is called plasma beta and is a measure of whether more energy per volume is stored in magnetic fields or in particle motion. In many cosmic sources, the plasma beta is around the value one, which is the same as energy equipartition. Moreover, in cosmic plasmas near temperature isotropy prevails, i.e. the temperature parallel and perpendicular to the magnetic field lines of the plasma is the same.
Explaining satellite data
For over a decade, the instruments of the near-earth WIND satellite have gathered various solar wind data. When the plasma beta measured is plotted against the temperature anisotropy (the ratio of the perpendicular to the parallel temperature), the data points form a rhombic area around the value one. "If the values move out of the rhombic configuration, the plasma is unstable and the temperature anisotropy and the plasma beta quickly return to the stable region within the rhombus" says Prof. Schlickeiser. However, a specific, detailed explanation of this rhombic shape has, until now, been lacking, especially for low plasma beta.
Collisions in the solar wind
In previous models it was assumed that, due to the low density, the solar wind particles do not directly collide, but only interact via electromagnetic fields. "Such assumptions are, however, no longer justified for small plasma beta, since the damping due to particle collisions needs to be taken into account" explains Dipl.-Phys. Michal Michno. Prof. Schlickeiser's group included this additional damping in their model, which led to new rhombic thresholds i.e. new stability conditions. The Bochum model explains the solar wind data measured significantly better than previous theories.
Universally valid solution
The new model can be applied to other dilute cosmic plasmas which have densities, temperatures and magnetic field strengths similar to the solar wind. Even if the diagram of temperature anisotropy and plasma beta does not have exactly the rhombic shape that the researchers found for the solar wind, the newly discovered mechanism predicts that the values are always close to one. In this way, the theory also makes an important contribution to the explanation of the energy equipartition in cosmic plasmas outside of our solar system.
Bibliographic record
R. Schlickeiser, M. J. Michno, D. Ibscher, M. Lazar, T. Skoda (2011): Modified temperature-anisotropy instability thresholds in the solar wind, Physical Review Letters, 107, 201102, doi: 10.1103/PhysRevLett.107.201102


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|Network Marketing Information
The MLM Revolving Door Syndrome
In the 15+ years I've been involved with network marketing, the number of people who come and go never cease to amaze me! Sometimes it seems like a revolving door.
On the positive side, thousands of new people discover network marketing all the time. They have always wanted to start their own business and are attracted by the huge income potential of MLM. Or they need a part-time source of income. Or, perhaps they've been caught up in the huge, never-ending layoffs and corporate downsizing that seem to be a permanent part of the new information-driven economy. They see network marketing as a way to escape the Rat Race forever!
Whatever the reason, they are entering this industry in droves. And that is good news for you and I!
On the negative side, however, most of these people flounder around for months, or even years, like a fish out of water, and never really discover how to make network marketing work for themselves. They buy into too much of the hype and half-truths that seem to proliferate in MLM advertising, expecting a large income in just a few months without much work or investment.
Unfortunately, some of us continue to promote this image of network marketing, even though we know it is completely untrue!
Perhaps that explains why so many newcomers believe that all they have to do to be successful is just send out a bunch of spammy emails and the money will come rolling in!
I've spent a lot of time and effort showing the newcomers in my downline the kind of work that is necessary for success. But all too often, these newcomers pay little attention to it. They've seen all the ads telling them that they don't have to do any work, that a certain program practically builds itself, or their upline will be giving them massive amounts of spillover.
They don't seem to understand that this is a business, not a chain letter game. And all too often, this is partly our fault. Some of us are so eager to sign up new distributors that we'll tell them anything.
So our MLM newcomer may run out and send out a few over-hyped, anonymous emails to a cheap list and then wait for the money to roll in.
When nothing happens, our unhappy newcomer then decides "the program doesn't work." (How many times have you received an MLM mailing with the words "This one really works" in the subject line? I get them all the time).
That starts our newcomer on a frustrating journey from one MLM program to another. They may join 5 or 6 all at once on the theory that at least one must work! They may sign up under a sponsor that promotes the "program of the month," and jump into everything new that comes out. Never does it enter their mind that "programs" neither work nor don't work!
What does or does not work is their personal success system. A good network marketer can earn a huge income in even the worst of programs, with the poorest compensation plans. But the best program in the world is not going to work for someone who doesn't understand how to be a successful network marketer and businessperson!
Some of these people finally do learn how to be successful. Usually it is only after wasting a lot of time and money. Unfortunately, most people finally quit in disgust and go out and give network marketing a bad name to their friends and family! And that makes it all the harder for the rest of us.
How many prospects have you talked to who tell you that their best friend "lost his shirt" in one of those "MLM pyramid scams?"
Contrary to popular belief, it takes training and education and investment to become a successful network marketer. No doctor was born with the knowledge of how to practice medicine. Nor was any successful network marketer born with the knowledge of successful recruiting and downline support.
Network marketing requires knowledge of effective marketing techniques, salesmanship, and basic business skills. If you are doing it online, it also requires computer and Internet skills, too.
On top of that, it requires the ability to work with people, the ability to follow a plan, discipline, and ongoing investment.
Fortunately, with the proper training, none of this is very difficult to learn. We hear a lot about "duplication" in this industry. And that is really all duplication is: learning effective techniques, using them, and teaching your downline to do exactly the same thing.
As professionals, it is essential that we pass that along to the downline we are building. I am tired of seeing so many newcomers pass through the revolving door. And I'm tired of hearing people refer to our business as a "pyramid scam."
Network marketing is a wonderful business. Almost anyone can learn to do it effectively and profitably if they are taught and if they have the desire.
It offers average people the means to a large income without a large initial investment. (But that doesn't mean it doesn't require investment). And it offers us the personal freedom and time to pursue other goals in life, unlike most corporate jobs.
This is the real message we should be sharing with prospects, not the hype that abounds online. We may sponsor a few less people. But I suspect that we won't be sponsoring so many people that are in and out of the revolving door giving our business a bad name.
(c) 2004 by Linda J Bruton
Linda Bruton has been a full-time network marketer for over 15 years. Be sure to visit her Network Marketing Tips weblog for weekly tips, tricks, secrets and resources for building a full-time MLM business online.
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I Could Have Quit $1,000,000 Ago
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Business Team Leadership: Pull Them, Dont Push Them
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