Overview of Assessment Tool for Human Resources Strategic Planning

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Overview of Assessment Tool for Human Resources
Strategic Planning

• Thomas Bossert, Ph.D.
• Harvard School of Public Health

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Strategic Guide for Assessing Context of Health
Workforce

• WHO requested a rapid assessment of the systems
  that are needed to support human resources
• Financing
• Education
• Management
• And
• The political feasibility of reforms
• Sequencing Investments
• Strategic Guide for Assessing Financing,
  Education, Management and Policy Context for 
  Health Workforce Development

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Strategic Guide Framework
Module-specific factors ? Cross-Cutting Problems ? Cross-Cutting Problems ? State of HRH ? State of HRH ? System goals? System goals? Health goals
Financing Education Management Politics Traditional Problems Job Change Multiple Job Holding Absenteeism Underemploy- ment Motivation Staff Rotation New Issues Migration Premature Death Traditional Problems Job Change Multiple Job Holding Absenteeism Underemploy- ment Motivation Staff Rotation New Issues Migration Premature Death HRH Level (how many?) HRH category HRH Distribution (where? who?) Within HRH-category skill-mix Geographical location Sector Gender HRH Performance (what do they do? how do they do it?) Quality (clinical service) Efficiency HRH Level (how many?) HRH category HRH Distribution (where? who?) Within HRH-category skill-mix Geographical location Sector Gender HRH Performance (what do they do? how do they do it?) Quality (clinical service) Efficiency Quality Efficiency Equity Sustainability Quality Efficiency Equity Sustainability Health Status Financial Protection Citizen Satisfaction
Example Education module Example Education module Example Education module Example Education module Example Education module Example Education module Example Education module Example Education module
Low middle/ high school graduates Low middle/ high school graduates Leads to Limited health professions applicant pool Leads to Insufficient HRH level Leads to Compromised quality/equity Leads to Compromised quality/equity Leads to Unsatisfactory population health status Leads to Unsatisfactory population health status
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Densities, Distribution and Performance

• Recent research suggests that densities of health
  workers are related to health outcomes
• Unequal distribution means different densities
• Ethiopia
• 0.3 physicians and 2.05 nurses per 10,000
  population among the lowest in Sub-Sarahan
  countries
• Geographic and gender inequalities
• Difficult to achieve MDGs in health with this
  workforce Proposed expansion of Health Officers
  and Health Extension Workers

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Worker Density and Mortality
Anand Baernighausen 2004
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Improvements in geographic distribution of
physicians (2002 2006)
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Cross Cutting Problems

• Traditional HR concerns continue
• Worker motivation
• Absenteeism
• Job rotation
• Multiple job holdings
• New HR priority concerns
• Out Migration
• Premature deaths from HIV/AIDS

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Financing Module

• Proportion of budget spent on health overall and
  on salaries vs. other inputs
• Ethiopia is very low on health 4 GDP
• But within benchmarks on salaries 60
• Allocative efficiency of wage bill
• Reasonable public wage bill in relation to per
  capita GDP but salaries are low relative to other
  options
• Hard to measure efficiency in terms of
  performance

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HRH Earnings relative to other professions
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Education Module

• Education Funnel from high school graduates to
  employment
• Ethiopia
• Small pool of high school graduates (even for
  SSA)
• High application, acceptance and retention rates
  but low number of places
• High quality of physicians and registered nurses
  (internationally competitive)

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Management Module

• Macro level of management
• Civil service characteristics
• Decentralization
• Leadership Capacities
• Micro level
• Modern management practices (e.g. performance
  based evaluation, HRMIS)
• Working conditions, logistics and supplies
• Public/Private interaction

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Analysis and Sequencing

• Assessment of Indicators of Modules
• Prioritization Criteria
• Selecting Reform Options
• Sequencing based on
• Tradeoff on magnitude of increase in densities
• Tradeoff on widening or deepening

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Political Feasibility of Reforms

• Key stakeholders positions on reform options
• Donors
• MOH,MOE and MOF
• Associations
• Political Parties
• NGOs and private providers

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Conclusion

• Assessment Tool can be used to help develop
  National HRH Strategies by identifying gaps not
  only in terms of HR densities needed to reach
  MDGs but also
• Financing capacity to provide funding for
  increasing densities
• Education capacity to provide pool of graduates
  and provide training
• Management capacity to support and motivate
  workforce
• Political feasibility of improving these health
  and education systems

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Methods for Projecting Supply and Demand for HRH
Strategic Planning

• Thomas Bossert, Ph.D.
• Harvard School of Public Health

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Projecting HRH Needs for Strategic Planning

• Framework for HRH need assessment
• HRH Level Current Stocks / Densities
• HRH Requirements Supply/Demand Projection
• HRH Types Skill mix
• HRH Distribution Factors Measurement

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Factors affecting HRH demand

• Health Workers Demand
• Demand for health services
• Population demographic characteristics
  population size, age structure
• Epidemiological factors disease patterns
• Socio-economic factors income, education
• Behavioral factors utilization patterns
• Health Service Policy and Resources
• Technology Service provision patterns
• Finance / budgets

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Factors affecting HRH Supply

• Health Workers Supply
• HRH production / training capacity
• Human capital stocks Education systems
• Other resources
• Global, regional, local exit and entry forces,
  labor market conditions
• Health Workers Attrition / Loss
• Retirement, Death, Out-migration
• Career change

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Stocks-Flows
Inflow Education In-migration
Production of Health
Stock of Health Workers
Coverage Motivation Competence
LEVEL, TYPE, DISTRIBUTION
Retirement Disability/Death Out-migration Outflow
JLI 2004
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Health Service Coverage and Worker Density
JLI 2004
WHR 2006
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Counting Active Health Workers

• Professional registration
• Government reporting system
• Facility based assessments
• Labor force surveys
• Census
• Others tax returns

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Supply Projection
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Methods of supply projection

• Total number projection
• Trend projection
• In- and out- moves method
• Stock and flow projection
• Demographic method
• Worker characteristics composition

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Total number projection
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In and out move method
Stock of Health Workers
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Stock of Health Workers
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Demographic method
Inflow Education In-migration
Stock Demographic of Health Workers
Outflow Retirement Disability/Death Out-migration
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Evolution of Nurse Age Structure
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HRH RequirementsEstimation
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HRH Requirements projection approaches

• HRH per population approach (density projection)
• Service target approach
• Health care demand approach
• Health needs approach

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Data requirements
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HRH per population approach
Current Population Level
HRH Requirements
Current level of HRH Density
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Service target approach
Future health systems scenario and health service
requirements
Historical service trends Health demand
Health service development
HR Productivity
HRH Requirements
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Health care demand approach
Current Health care utilization (Survey)
Statistical Model
Population characteristics age income sex
education
Future health service requirements
Population and socio-economic trends
HR Productivity
HRH Requirements
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HRH Skill Mix
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Skill mix

• Types of Professionals
• doctors, nurses, pharmacists, dentists,
  technicians, physiotherapists
• Professional vs. auxiliary
• Clinical officer
• Medical Assistant, nurse assistant
• Generalist vs. specialist
• Multi-skilled staff

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Physician Nurse ratios
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Skill Mix Decision Factors

• Technical
• Disease patterns, types of service demand
• Training capacity
• Human resource base
• Economic
• Cost containment,
• Cost-effectiveness,
• Quality quantity tradeoff
• Political

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Approach to determining skill mixes

• Task analysis
• Activity analysis
• Daily diary
• Case mix/ patient dependency
• Zero base re-profiling
• Job analysis interviews
• Professional judgment
• Group discussion / brainstorming

Buchan et al 2000
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Task Shifting

• Shift to lower-level cadre(s)
• Shift to a new cadre (mid-level health workers
  with specific skill set)
• Other terms
• Task delegation
• Skill delegation
• Skill substitution

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HRH Distribution
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Aspects of distribution

• Spatial / Geographical
• Regional disparity
• Urban concentration
• Functional
• Public vs private
• Dual practice / Moonlighting

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Determinants of Individuals Decision
Allowances
Salary
Other Payments
Other Opportunities
Spousal opportunities

• Work Load
• Intensity
• Controllability

Children education

• Job Description
• Scope
• Controllability

Other Amenities Urban vs. Rural Areas
Professional Satisfaction

• Rural Background
• Scope
• Controllability

Medical litigation risk
Team Support

• Social Views
• Social Responsibility
• Altruistic Mindsets

Facilities and Other Support
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Measurement of HRH Distribution
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Tanzania Health Worker Profile
Types Public Private Non-profit Public Urban Rural Urban
Doctors Generalists 339 108 63 66 186 324 36
Doctors Specialists 209 69 42 65 180 132 58
Clinical officers 2,606 455 544 72 566 3,042 16
Nurse officers (RN) 2,069 269 952 63 865 2,425 26
Enrolled Nurses 4,654 710 2,075 63 1,256 6,183 17
Dentists 117 13 17 80 49 98 33
Pharmacists 88 10 13 79 56 55 50
Pharmacy technicians 77 11 19 72 25 82 23
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Thailand physicians geographical distribution
Note data from national population and
household census, 2000 Source Thammarangsri
(2005)
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Discrepancy by data sources Thailand HRH Stocks