Modelling Human Resources for Health

Proochista Ariana

University of Oxford Department of International Development

13-14 December 2008

Conventional Models/Approaches Used

• Needs-based model• Demands-based (utilization) model• Health workforce to population ratios• Service target-setting approach• Adjusted service target approach

Needs-based Model

• Estimates future requirements based on estimated health deficits of the population

• Projects age- and gender-specific ‘service needs’ based on service norms and morbidity trends

• Converts projected service needs to persons requirements using productivity norms and professional judgment

Needs-based Model

• Assumptions– All health care needs can and should be met– Cost-effective methods to address the needs can

be identified and implemented– Resources are used in accordance with needs

• Advantages– Is independent of the current health service

utilization– Is useful for some programmes such as prenatal

and child care

Needs-based Model

• Limitations– Requires extensive data– No consideration for users’ perspectives based on

their values, culture and traditions– Does not take into account different perceptions

of client/user as viewed by the various health workers

Needs-based Model

• First, baseline supply projections of physicians need to be determined using the following:

ln(physicians per 1000 populationt) = 0 + 1 x yeart + t

Where,t - random disturbance term0 and 1 - unknown parameters to be estimated from the model

Needs-based Model• The need-based model estimates the following equation for all

countries i at time t:

sin-1(service targetit) = ß0 + ß1 x ln(physicians per 1000 populationit) + µi + t + it

Where,

µi - country fixed effectst - time fixed effectsit - random error termß0 and ß1 - unknown parameters to be estimated from the model

Demands-based (Utilization) Model

• Estimates future requirements based on current level of service utilization in relation to future projections of demographic profiles

• Commonly utilizes GNI as a predictor of demand for physicians

• Assumption– Current level, mix, distribution of health services are appropriate– Age- and sex-specific requirements remain constant in the future– Size and demographic profile of the population changes in ways

predictable by observed trends in age- and sex-specific rates of mortality, fertility and migration

Demands-based (Utilization) Model

• Advantages– Economically feasible targets due to no or little change in

population-specific utilization rates• Limitations– Requires extensive data– Factor in only economic growth and physician per capita

variables– Overlooks consequences of ‘errors’ arising from the

assumptions proving to be invalid– Produces a ‘status quo’ projection, since future population

segments are assumed to have similar utilization rates as base year segments

Demands-based (Utilization) Model

• This approach estimates the following relationship for country i at time t:

ln(physicians per 1000 populationit) = 0 + 1 x ln(GNI per capitait-5) + 2 x income leveli + µi + it

Where,µi - reflects a vector of country fixed effectsit - disturbance term0 and 1 - unknown parameters to be estimated from the model

Demands-based (Utilization) Model

• For each country at time t, the growth rate in GNI per capita was calculated as:

exp(1) - 1

from the equation:

ln(GNI per capitat) = 0 + 1 x yeart + t

Where,t - disturbance term0 and 1 - unknown parameters to be determined from the model

Health work force to population ratios

• Specifies desired worker-to-population ratio• Assumptions– Often based on current best region ratio or a

reference country, with a similar but presumably more developed health sector

• Advantages– Quick, easy to apply and understand

Health work force to population ratios

• Limitations– Provides no insight into personnel utilization– Does not allow for interaction between numbers,

mix, distribution, productivity and outcome– Base year maldistribution will likely continue in

target year

Health work force to population ratios

• The threshold density of physicians obtained from the equation in the needs-based model together with the population estimates for future years are used to calculate the health work force to population ratios

Service target-based

• Sets targets for the production and delivery of specific outcome oriented health services

• Converts these targets into HRH requirements by mean of staffing and productivity standards

• Assumptions– Standards of each service covered are practicable

and can be achieved within the timescale of the projection

Service target-based

• Advantages– Relatively easy and understandable– Can assess interactions between variables

• Limitations– Potentially unrealistic assumptions

Adjusted service target approach

• Identifies service needs based on epidemiologic and demographic profile, and programmatic targets

• Identifies tasks and skills required to delivery the evidence-based strategic interventions for the specific programmes, based on functional job analysis

• Estimates time requirements for each intervention, based on time-motion studies or expert opinion

• Translates the time requirements into adjusted full-time equivalents, based on productivity

Adjusted service target approach

• Assumption– Effective evidence-based interventions can be delivered in

all settings/conditions• Advantages– Useful for specific programmes– Looks at efficiency issues and potential for combination of

skills– Useful to identify training needs– Goes beyond the traditional occupation-based

training/practice towards competency-based training and service

Adjusted service target approach

• Limitations– Requires detailed workflow studies or expert

assessment and opinion– Can only be effective if infrastructure, supplies

and logistics are in place to support HRH

Common limitations of current studies and/or approaches

• Use only one or few aspects of health care as proxy for healthcare needs

• No consideration for users’ perspectives based on their values, culture and traditions

• Does not take into account different perceptions of client/user as viewed by the various health workers

• Focus only on ‘professional’ health work force such as physicians and nurses and does not take into account other health workers (e.g. traditional birth attendants), community workers and other health-related external resources

Summary Analysis of Current Methods

• The different methods have addressed the supply side of the health workforce, the demand side, or both

• Current models do not take into account the dynamic, multi-disciplinary and complex nature of health and health care delivery

• New thinking is required that acknowledges the dynamic and complex processes that contribute to health and adopts a more multi-disciplinary and integrated approach in understanding, planning and addressing HRH requirements

What factors need to be considered?

• Identify the needs for services• Identify the interventions required to deliver services

at each level of care• Identify the tasks and skills required to deliver the

interventions at each level of care• Estimate the time requirements for each

intervention at each level of care• Identify possible overlap/synergies between skills

and possible time savings effected by combining various skills

Identification of needs for services

• Currently:– Incidence and

prevalence of health problems

– Demographic characteristics of the population

– Targets identified in health sector strategic plan

• Proposed:– Include global burden of disease

(GBD) utilizing trend of GBD over time to account for the changing/dynamic patterns of disease

– Include country- and/or area-based ecological studies of the incidence and prevalence of health problems and of the demographics of the population

– Include subjective valuation of health by the general population

– Consult general population in health sector strategic planning to identify health targets

– Application of systems dynamic modelling

Identification of interventions

• Currently:– Expert opinion on

interventions needed– Use existing health

programme strategies such as maternal and child health, prenatal, family planning, HIV/AIDS, etc.

• Proposed– Include opinion of other health

workers (both formal and non-formal/professional and traditional) on interventions needed

– Consult general population in planning and design of health programme strategies

– Establish a qualitative and quantitative, epidemiological and ecological evidence-base on the effectiveness of existing health programme strategies

– Application of systems dynamic modelling

System Dynamic Modelling• The methodology involves development of causal diagrams and policy-

oriented computer simulation models that are unique to each problem setting

• A central tenet is that the complex behaviours of organizational and social systems are the result of ongoing accumulations - of people, material or financial assets, information, or even biological or psychological states - and both balancing and reinforcing feedback mechanisms

• System dynamics uniquely offers the practical application of these concepts in the form of computerized models in which alternative policies and scenarios can be tested in a systematic way that answers both “what if” and “why”

Model of Chronic Disease Prevention

Chronic Disease Prevention Model: 3 Scenarios

Identification of tasks and skills required

• Currently:– Functional job analysis

• Proposed:– Identify existing and inherent

health-related knowledge, tasks, skills and behaviours in the community/area synergistic to the requirement

– Include attitudinal personnel factors such as job satisfaction, personal development, continuing education, relationships, etc.

Functional Job Analysis

Estimation of time requirements for interventions

• Currently:– Time-motion studies– Work-sampling

• Proposed:– Patient flow

model/analysis– Geospatial, spatio-

temporal,dynamic modelling/analyses

– Logistics and operations research analysis

Work-sampling• Collects data at intervals of time. For example, data might be

collected by determining exactly what a worker is doing four times each hour.

• Sometimes the data are collected by observing the worker in action at the point in time selected for the observation.

• In other studies the workers use logs to self-report their activity.• In some cases the intervals between observations are of fixed

duration.• In other cases the observations occur at randomly chosen moments

in time.• An inference is made about the portion of overall work time spend

on an activity based on the percent on the percent of observations that related to that activity.

Time-motion Studies

• Uses and observer to record exactly how much time is being devoted to each task.

• Much more labor-intensive method of data collection, because it requires a one-on-one observation.

• Observers must follow the subject continuously for extended periods of time.

• Each activity and its duration must be recordd on a data collection instrument.

Patient flow analysis

• Creation of a patient flow model using discrete event simulation

• Utilize a physician scheduling analysis tool (similar to work-sampling methods)

Spatio-temporal Models

Spatio-temporal Models

Combination of overlapping/synergistic skills

• Currently:– Productivity analysis

• Proposed:– Identify existing, traditional

and inherent health-related knowledge, tasks, skills and behaviours in the community/area synergistic to the tasks/skills requirement

– Dialogue and cooperation between formal health work force, non-formal health workers and community at large in terms of health service productivity