Part III: MEASUREMENT STRATEGIES AND CASE STUDIES
6 Measuring expenditure on the health workforce: concepts, data sources and methods
6.5 Summary, conclusions and further developments
This chapter has focused on the tools, methods and usual means of measuring expenditure on the health workforce as a component of overall monitoring and evaluation of HRH strategies. It has been argued that there are many advantages of an integrated estimation of HRH expenditure within routine accounts estimates – either the system of national accounts or, prefera-bly, health accounts. There are certainly economies of scale and quality gains from a comprehensive and harmonized process in collating and processing the required data, and in identifying and filling informa-tion gaps through complementary data collecinforma-tion and analyses.
To complement or refine available estimates on HRH expenditure, close collaboration between health accountants and national accountants is advisa-ble. When the data are taken from national accounts records, the most important adjustment required is an expansion of the boundaries of the health system to reach concordance with health accounts boundaries.
As such, there is an advantage in generating the data as a bottom-up exercise (estimating each of the various components independently and then adding them up);
this allows greater flexibility to use the data in different ways according to specific needs. When full records and updates of HRH expenditure are not readily avail-able, a series of progressive steps can be taken to move towards a comprehensive assessment: from sim-ply persons working in health services delivery to those across the whole spectrum of health system activities, from measuring just wages and salaries to inclusion of non-wage contributions, or from government expendi-ture to all (internal and external) financial sources.
Ensuring the quality, coherence, consistency and rele-vance of the data – which may be drawn from multiple sources – requires continuous verification during com-pilation, integration, adjustment and modelling (39).
This may include data validation and adjustments (to correct biases, errors, incompleteness and disconti-nuities); conceptual adjustments (for example to bring figures using definitions from national accounts in line with those from health accounts); comprehensive-ness adjustments (to cover hidden activities, informal
payments and others); and balancing adjustments (for example between supply and demand for health labour).
In addition, different policy concerns may require a specific breakdown of HRH expenditure estimates or additional analyses beyond standard health or national accounting methods. Guidelines for health sub-accounts to produce additional estimations are being developed and tested by WHO (40, 41) in the follow-ing areas:
t sub-accounts for specific diseases and pro-grammes (including malaria, reproductive health, HIV and tuberculosis services);
t sub-accounts on child health programmes;
t regional health sub-accounts (distributional tables for specific regions within a country – particularly relevant for decentralized health systems);
t sub-accounts for specific population groups (dis-tributional tables in terms of expenditure allocation according to characteristics of health service cli-ents, such as by age, sex or other socioeconomic characteristics).
At the same time, it must be recognized that there are presently no specific guidelines for disentangling the whole set of health labour cost estimations, and this across the stages of the working lifespan. Based on measurement results from several countries, the need has been recognized for further development in the following areas in order to reach a comprehensive assessment of expenditure on HRH:
t boundary problems to distinguish between labour resources in the health system devoted to health-care services delivery versus other functions and activities;
t challenges regarding completeness and coverage of information on HRH stock and distribution (for example lack of centralized database, lack of suffi-cient detail for disaggregation);
t problems with consistency of HRH information across various data sources, such as lack of stand-ard practices to classify workers by occupation and education; differences in practices to esti-mate full-time equivalents across health worker groups; potential double-counting of health work-ers (for example due to multiple qualifications or job positions); and, given such differences, resulting difficulties in interpreting and comparing statistical findings across and within countries.
In sum, strengthening of national information systems, better use of available data and intensified efforts for harmonizing definitions and measurement units rele-vant for health labour accounting should ensure that investments in the health workforce are appropriately
Measuring expenditure on the health workforce: concepts, data sources and methods
monitored and evaluated. This is critical information that could help address many important policy questions, such as the costs of scaling up health interventions or providing incentives for improving staff retention and motivation to ensure high quality and efficiency of services.
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Use of facility-based assessments in health workforce analysis
BOLAJI FAPOHUNDA, NANCY FRONCZAK, SHANTHI NORIEGA MINICHIELLO, BATES BUCKNER, CATHERINE SCHENCK-YGLESIAS, PRIYA PATIL
7.1 Introduction
The global health literature demonstrates that health-care service coverage and quality are directly correlated with health worker numbers and perform-ance. For instance, the World Health Organization (WHO) has presented evidence showing that cover-age of selected primary health-care services, including maternal, newborn and child health interventions, tend to rise with higher national health workforce densi-ties (1). Using the Millennium Development Goals as the benchmark, WHO reports that countries with the highest shortfalls in numbers of physicians, nurses and midwives are the ones most at risk of not meeting cov-erage targets. The African region – home to only 3% of the estimated 59.2 million health workers in the world but having 24% of the global burden of disease – is the area hardest hit by health worker shortfalls and imbal-ances worldwide (1).
Securing improvements in the size and quality of the health workforce is important for achieving regional and country-specific Millennium Development Goals in health. Overcoming human resources for health (HRH) shortages and imbalances requires strengthening edu-cation and training programmes for health workers, improving health sector working conditions (including staff salaries and benefits) and forging cooperation and collaboration in health workforce management within and across countries. Evidence-based moni-toring of health workforce dynamics is important for ensuring that policy and programmatic inputs lead to the expected outcomes.
Often, a lack of comprehensive, timely and reliable data on HRH results in poor knowledge of workforce status and curtails development of evidence-based policies among national and international stakeholders. Several factors have contributed to the weak information and evidence base on the health workforce in many low- and middle-income countries. These include lack of a com-mon framework from which to understand HRH issues;
poor data availability and quality; imprecise definitions
and classifications of certain health worker catego-ries; weak technical capacity to conduct in-country workforce analysis; lack of appropriate measurement tools; and underinvestment in national health informa-tion systems (1–3). In particular, lack of standardized approaches to HRH assessment limits the potential for comparative analysis over time and across countries to better understand how different situations, policies and interventions impact the performance of human resources and health systems and, ultimately, popula-tion health outcomes.
Health facility assessments (HFAs), the focus of this chapter, are tools for gathering data that are a potentially important source of information for health workforce monitoring. A number of countries already conduct such assessments, and demand for them is increas-ing. Health facilities refer to service delivery points in the formal health sector, including hospitals, health centres, dispensaries and health posts. HFA protocols capture real-time information (i.e. at the moment of the assessment) on a key component of the overall health system: facility-based service delivery. Depending on the nature of the data collection instruments, HFAs can provide detailed information on health workforce availability, distribution, qualifications, skills mix, train-ing and performance. This information can be used to determine, for example, how existing staffing pat-terns relate to desired or planned staffing levels, how well staff members’ qualifications match their assigned scope of work and the nature and extent of geographi-cal or other staffing imbalances. HFAs can also provide insight into the broader health labour market context, including management practices and other features of the work environment (for example infrastructure and availability of medical supplies and equipment), and how these variables affect health worker supply and performance. In short, HFAs can inform workforce pol-icy by telling us what is happening on the ground, in the real world of service delivery.
The main objective of this chapter is to describe the current and potential usefulness of HFAs as a source of
7
information for health workforce planning, management, monitoring and policy-making. Illustrative examples are presented based on empirical data from HFAs con-ducted in Kenya, Nigeria and Zambia. Facility-based assessments cover a broad array of data collection techniques, including facility audits, observations of services delivered, interviews with service providers and interviews with clients. These various methods, along with other practical considerations in planning an HFA, are reviewed here. However, this chapter does not elaborate step-by-step instructions on designing and implementing facility assessments; for general information and relevant resources see International Health Facility Assessment Network tools (4, 5).
7.2 How facility-based
assessments can be used for health workforce monitoring
As detailed in Chapter 1 of this Handbook, there are three interdependent stages in the lifespan of the health workforce: (i) pre-service or entry into the workforce;
(ii) active workforce; and (iii) exit from the workforce.
Ongoing measurement and monitoring of perform-ance indicators for each of the three stages is needed to determine the health system’s readiness and abil-ity to maintain a sufficient stock of qualified workers.
Because the stages are interactive and interdepend-ent, monitoring must be holistic rather than fragmentary, focusing on the whole rather than little slices of the pie.
While detailed analysis of the entry and exit stages is beyond the scope of HFAs (for example health edu-cation outputs and costs, and mortality and migration among health workers, respectively), facility-based sources can provide valuable information to comple-ment data obtained using other methodologies (such as special studies on education or migration).
Box 7.1 shows a list of indicators that can potentially be measured for each of the workforce stages using HFA data. Most population-based sources of health workforce statistics (for example population censuses, labour force surveys) tend to relate workforce data to the general population; while important in their own right, they provide little insight into the service delivery environment, service quality or other operational fac-tors within the health system that can play a major role in workforce performance. HFA data can help address this information gap by describing health labour dynam-ics at facility-based service delivery points.
Box 7.1 Core health workforce indicators potentially measurable with HFA data
Entry stage of the working lifespan tNumber of new medical/health graduates
entering the facility-based health workforce tRatio of new medical/health graduates entering
the based workforce to the total facility-based health workforce
Active workforce stage Supply
tStock or total number of facility-based health workers
tNumber of facility-based workers relative to total (catchment) population
tNumber of facility-based workers relative to planned staffing norm
tNumber of staff per health facility (by type of facility or services offered)
Distribution
tSkills mix of facility-based staff
tGeographical distribution of facility-based staff tAge and sex distribution of facility-based staff Capacity, motivation and performance tLevel and field of education among
facility-based staff
tYears of professional experience among staff working at the facility
tStaff receiving in-service training during a reference period (by type of training)
tServices provided by staff during a reference period
tProportion of staff working full time versus part time at the facility
tProportion of staff assigned to the facility (in post) working at the facility on the day of the assessment
tProportion of staff receiving (non-monetary) incentives at their job
Exit stage
tFacility-based health workforce attrition rate (by reason for leaving workplace)
tRatio of facility-based health workers entering the workforce to those exiting the workforce
Use of facility-based assessments in health workforce analysis
7.3 Overview of key HFA methodologies
This section provides an overview of issues of impor-tance when planning an HFA, and describes the methods and focus of data collection for several dif-ferent HFA tools developed by difdif-ferent private, public
This section provides an overview of issues of impor-tance when planning an HFA, and describes the methods and focus of data collection for several dif-ferent HFA tools developed by difdif-ferent private, public