A NEEDS-BASED ANALYTICAL FRAMEWORK FOR HEALTH HUMAN RESOURCES PLANNING

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A NEEDS-BASED ANALYTICAL FRAMEWORK FOR HEALTH
HUMAN RESOURCES PLANNING

• Stephen Birch

• Centre for Health Economics and Policy Analysis,
  (CHEPA) McMaster University Hamilton
• Health Economics Research at Manchester (HERMAN)
• University of Manchester, UK
• Centre for Health Economics Research and
  Evaluation (CHERE)
• University of Technology, Sydney
• Health Economics Unit, University of Cape Town,
  SA

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HEALTH HUMAN RESOURCES PLANNING
Focus Impact of demographic change Effect
of aging population on the provider requirements
Effect of aging workforce on capacity to meet
requirements General approach
Provider-population ratios applied to
population projections (possibly with age and sex
adjustments) Estimate shortfalls/surpluses
in providers and calculate changes in the size of
training programmes required to eliminate
imbalances How many additional physicians do we
need to train?
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HEALTH HUMAN RESOURCES PLANNING

• Performed in isolation of other aspects of health
  care policy and population health
• Research questions implicit, unclear or poorly
  defined  
• How many health care providers are required to .
  . . serve future populations in the same way as
  the current population is served?
• Requirements determined by factors beyond control
  of policy
• Underlying assumptions
• Population age structure determines service
  requirements (i.e., epidemiology constant)
• Provider age structure determines the quantity of
  care provided (i.e., production function constant)

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EXAMPLE HHRP FOR DENTISTS IN UK (Birch and
Maynard 1985)
Method Project service use-population ratios
onto expected future population Requirements A
ssumed needs by age group constant Ignores
impact of diet, oral hygiene, fluoride Supply As
sumed services per provider constant Ignores
impact of technology (multi chairs,
hygenists) Outcome No evidence of excess
supply Orthodontics (service deepening or
supplier induced demand)
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EXAMPLE HHRP FOR PHYSICIANS IN CANADA

• Royal Commission Maintain pop-phys ratio(PPR)
  at 850
• Increase med. school intake for expected
  population growth
• 1991 Barer-Stoddart report - PPR fallen rapidly
  population growth less than projected
• Stabilise PPR at 500-550 through package of
  measures including reductions in med school
  intake
• 1998 Canadian Medical Association (CMA)
  population growth exceeded physician growth over
  post 91 period 5 less docs per 100,000 (PPR
  growth 2.6 or less than 0.5 per year)
• CMA estimated physician-population
  ratio to fall by 31 over 25 years - medical
  school intake increased

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EXAMPLE HHRP FOR PHYSICIANS IN CANADA
Applying 1 annual reduction in needs and 1
annual increase in productivity to CMA estimates
produces reduction of 27 in effective PPR
over same period (Birch et al. 2007) 2004 PPR
471 much less than previous targets CMA
acknowledge overestimated population growth and
physician retirements so potential shortages
inflated Any changes in productivity or needs
would further reduce shortages or produce
surplus Between 1961 and 2003 63 increase in
physicians after allowing for population
growth
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IMPLICATIONS OF TRADITIONAL MODEL PEADIATRICIANS
IN US
2004 Shipman et al. Numbers of pediatricians
and children in US increase by 64 and 9
respectively by 2020 To maintain workloads
need to expand services and expand patient
populations beyond current age groups 2008
American Academy of Pediatrics Recommendations
for cholesterol screening and treatment for
children age 2 and over
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AN EARLY DIAGNOSIS?
Progress in medicine does not focus on doing
existing things more cheaply and simply, but on
discovering complex and difficult things to do
that previously could not be done at all . . .
. . .the NHS was a miscalculation of sublime
dimensions Enoch Powell, Minister for Health,
(1962)
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CONCEPTUAL FRAMEWORK
HHRP occurs within, not independent of, health
care planning Health care planning occurs
within, not independent of, public policy
planning. HHRP incorporates dynamic and
interacting nature of factors previously
conceptualized as constant and independent.
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FEATURES OF CONCEPTUAL FRAMEWORK
Evidence-based approaches to needs  Need
independent of availability or use  Derived
nature of requirements  Requirements derived
from the need for services   Production of
health care  Services produced from human and
non-human resources. Contextual nature of
requirements  Service contexts define
opportunities and constraints for HHRP Range of
policy levers Training seats just one of many
policy levers
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ANALYTICAL FRAMEWORK
Two independent components Provider
supply How many providers are (or will be)
available to deliver health care services to the
population? Provider requirements How many
providers are required to ensure sufficient
flow of health care services to meet the
needs of the population?
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DETERMINANTS OF PROVIDER SUPPLY
Stock of individuals M Number of providers
potentially available to contribute to service
production Flow of activities, Ls generated
from the stock Quantity of input provided
(e.g., time spent in the production of services)
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ACTIVITY ADJUSTED SUPPLY Ns
lij, participation rate of stock, kij, activity
rate of participating stock. W FTE hours
Stock of providers
Mt-1ij is stock of providers in the previous time
period, t-1
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PROVIDER REQUIREMENTS
Traditional approach  Implicit analytical
framework using demography, P, and current level
of providers N/P as constant
Or, provider-population ratio replaced by service
use -population ratio, Q/P . Requires link
between services and providers , N ij/Qij,
N ij/Qij,, productivity, implicitly assumed
constant over time
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BEYOND DEMOGRAPHIC CHANGE AN ENHANCED FRAMEWORK
Need for services not part of traditional
approach Introducing Hij the average level of
needs in group i , j
Determinants of requirements DEMOGRAPHY Pij
Size and age-gender profile of the
population  EPIDEMIOLOGY Hij/Pij levels and
distribution of needs in the population LEVEL OF
SERVICE Qij/Hij the level of service
associated with each level of need PRODUCTIVITY
Nij/Qij the inverse of the average level of
productivity of providers serving population
group Pij
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NEEDS BY AGE ACROSS COHORTS
Data from multiple pop health surveys
(1994-2005) For each year, estimate health
indicator by age and sex Single data set
describes health by age and birth
year Regression models used to describe how the
age pattern of health varies by birth cohort and
sex Health indicators Mortality,
morbidity,self-assessed health (55-84) Risks to
health (smoking and alcohol use) (25-54)
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AGING AND HEALTH OVER TIME
Rates of increase of mortality and mobility
problems by age is greater for older cohorts.
more recent birth cohorts are living
longer chance of having mobility problem at 70 is
6.7 for male born 1939 but 7.8 born in
1921 Increasing probability of pain with age but
lessening over time Increasing probability of
reporting poor health by age but constant over
time
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EXAMPLE - MOBILITY
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APPLYING THE ANALYTICAL FRAMEWORK SIMULATION
MODELS
General simulations Illustrate relative and
combined impacts of different policies Software
Vensim Population Combined Atlantic
provinces Needs Age-gender levels of health
Scenarios constant, trend, Canada  Providers
Hypothetical profession 2 different age
distributions (Data taken from several
professions) Planning period 40 years
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TOTAL ACTIVITY-ADJUSTED PROVIDERS OVER TIME
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EFFECT OF RETIREMENT SCENARIOS ON PROVIDER GAP
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EFFECT OF TRAINING SEAT SCENARIOS ON PROVIDER GAP
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EFFECT OF VARIOUS PRODUCTIVITY SCENARIOS ON
PROVIDER GAP
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EFFECT OF PROVIDER WORKED HOURS SCENARIOS ON
PROVIDER GAP
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COMPARISON OF POLICY SCENARIOS
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ADDITIONAL TRAINING SEATS REQUIRED TO ELIMINATE
PROVIDER GAP IN 15 YEARS
Needs Scenario
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CUMULATIVE EFFECTS OF POLICY SCENARIOS ON
PROVIDER GAP
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ADDITIONAL TRAINING SEATS PER ANNUM REQUIRED TO
ELIMINATE PROVIDER GAP IN 15 YEARS UNDER
COMBINIATION OF POLICIES
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SUMMARY
Separates the roles of changes in population
demographics, levels of health, levels of service
and productivity on the determination of HHR
requirements Avoids illusions of necessity
(or Roemers Law) in planning HHR and hence
perpetuating imbalances in HHR Provides a basis
for considering the impact of health care
policies on HHR