Towards needs-based health workforce planning for Universal

Health Coverage: A scoping review of analytical applications

James Avoka Asamani

Advisor, Human Resources Health Systems, WHO Regional Office for Africa
PhD Candidate, CHPE, North-West University, Potchefstroom, South Africa

Dr. Christmal Dela Christmals

Senior Lecturer, CHPE, North-West University, Potchefstroom, South Africa

Prof. Gerda M. Reitsma

Director, CHPE, North-West University, Potchefstroom, South Africa
 Background
§ The health workforce is a critical part of developing responsive health
systems that address routine population health needs and responding to
health emergencies, including outbreaks and pandemics.

§ However, defective health workforce planning has been the weakest link
in health systems planning over the years

§ World Health Assembly (WHA) resolution WHA69.19 called on countries to make

HWF investments based on a matching of “…the supply of health workers to
population needs, now and in the future” (GSHWF: HRH 2030)
 What is Needs-based health workforce planning?

§ An approach that makes an “… explicit consideration of population health needs,

direct measures of levels of health that give rise to need for care – and the planned
number and type of services to be provided to address those needs” (Tomblin
Murphy et al., 2012).
§ HWF requirement becomes a function of four primary measures:
o Demographic characteristics: The size, gender and age distribution
o Level of health: Disease burden and health risk factors affecting the age and
gender-specific groups of the population (epidemiology)
o Level of service: the type and frequency of health service necessary to address
the disease burden and risk factors to promote health, growth and development.
o Productivity or Standard workload: the the rate at which the services can be
provided to acceptable professional standards (or the volume that one
professional can deliver safely based on acceptable standards).
 Aim of the study
§ Although the theoretical underpinnings of the needs-based health
workforce planning framework developed and tested in many contexts,
its degree of uptake in actual planning processes is still limited.
o Murphy et al (2016) found that only 14% (18 out of 130) of national planning
documents were based on the needs-based approach.

§ We aimed to conduct a scoping review of the methodological

considerations in peer-reviewed papers of applied analytical models to:
o Harmonise understanding with a view of addressing any methodological gaps.
o Develop an open-access tools for policy-driven use in LMICs.
Methodology
 Literature search and selection

§ Conducted a general literature search via Google Scholar and PubMed in

February 2020 to frame the topic and understand the potential volume
and nature of evidence available.
§ A systematic search to identify relevant studies from 5 databases
(PubMed, Scopus, Web of Science, EBSCOHost and Google scholar).
§ Guided by the PRISMA-ScR Checklist (Tricco et al., 2018; Peters et al., 2020)
§ The search was last updated on 22 August 2020.
§ Screening and selection of studies done independently by two authors
who later compared notes, and where there were discrepancies, a third
author’s independent view was used for an amicable resolution.
Inclusion and exclusion criteria

§ Papers were included if they:

o Reported the use of health workforce planning models that link population health needs,
disease burden and population demography to health workforce requirements
o Employed methods and reported on findings of an analytical application of needs-based
health workforce requirement;
o Were published in the English language, and the full article of the publication was
accessible.

§ Those that described the conceptual approach to needs-based health workforce modelling
without analytical application were excluded
 Quality assessment of included studies
§ We did not find specific quality appraisal tools for needs-based HWF planning models (or even HWF analytical
models in general).
§ We adapted a quality assessment checklist of 27 from the following:
o Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS
Checklist) (Moons et al., 2014)
o The Phillips checklist for health economic models (Philips et al., 2006)
o Segal’s 7 key questions for needs-based health workforce models (Segal et al., 2018b)
o Murphy’s Criteria for fit-for-purpose health workforce planning tools (Murphy et al., 2016)
§ Each of the 27 item were assigned an unweighted point and the score (sum) interpreted as follows:
o 80% or more = very comprehensive and of high quality
o Between 70% and 79% = ‘quite comprehensive and of good quality
o between 50% and 69% = moderate comprehensiveness and quality.
o Scores below 50% = not comprehensive and of low quality.
 Data Analysis

§Descriptive analysis and narrative synthesis

oThe volume and characteristics of the studies
o Synthesis of the critical modelling considerations
made in the analytical applications of the needs-
based approach to health workforce planning
Findings
Search and inclusion
process
 Year of publication and country of origin
14 60%

12
12
50%
48%

10
9 40%
Number of included studies

Percent of included studies

36%
8

30%

20%
4

2 10%
2 8%
1 1
4% 4%

0 0%
Before 2000 2000 - 2004 2005 - 2009 2010 - 2014 2015 - 2020

Number of studies %
 Country of origin of the included studies

§ 88% (n=22) of the studies were from 11 countries (Australia, Canada, England, Guinea,
Ireland, Israel, Jamaica, Kenya, Singapore, South Africa and the United States).
o Three (12%) of the papers reported multi-country analysis
o Five (20%) were from Canada; 4 (16%) from Australia and 3 (12%) from England.

§ Three countries (Canada, Australia and England) accounted for 48% of the
publications included.

§ Only 4 papers (16%) were based on the context of low-and-middle-income countries,

of which three were from sub-Saharan Africa (Kenya, South Africa and Guinea).
 Summary of quality appraisal scores
§ Based on the criteria adopted, the papers scored between 57.7% and
88.5% with an average of 72% (95% CI: 69.5% - 75.9%).
§ Only five (20%) of the studies measured up to 80% or more of the
adopted criteria which were ‘very comprehensive and of high
quality’.
§ Another set of seven (28%) of the studies scored between 70% and
79% and were ‘quite comprehensive and of good quality’.
§ The rest scored between 50% and 69% and were moderate in terms
of comprehensives and quality.
Comprehensiveness and quality of studies included (overall scores)
Elisha et al., 2004 57.7%
Laurence et al., 2018 61.5%
Jansen et al., 2014 63.0%
Birch et al., 2013 63.6%
Tomblin Murphy et al., 2012 65.4%
Burke et al., 2013 65.4%
Vedanthan et al., 2019 66.7%
Gallagher et al., 2010 66.7%
Sukeri et al., 2015 68.0%
Tomblin Murphy et al., 2016 69.2%
Roos et al., 1999 69.2%
Konrad et al., 2009 69.2%
Bruckner et al., 2011 69.2%
Gallagher et al., 2013 72.0%
Murphy et al., 2014 73.1%
Birch et al., 2020 73.1%
MacKenzie et al., 2019 74.1%
Segal et al., 2013 76.9%
Ahern et al., 2019 77.8%
Roos et al., 1997 79.2%
Ansah et al., 2019 81.5%
Ansah et al., 2015 81.5%
Segal et al., 2018 84.6%
Murphy et al., 2017 84.6%
Laurence et al., 2016 84.6%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%
 The time horizon of models
§ Amongst the studies that
focused on long term
projections, the duration or
time horizon of the projection
Studies with
ranged from 3 to 33 years,
future with an average of 17 years.
No future projection
projection 48%
52%
§ 75% (n = 9) studies made the
projections for a time horizon
of ten (10) years or more.
Scope of application of need-based health workforce planning models

§ Three multi-country applications of the need-based health workforce

modelling
§ Only two papers reported the application of needs-based health workforce
models at the level of a national health system across several disease areas
or programs.
§ Most of the studies (n = 9, 36%) reported applications in specific disease
areas or programs within the scope of a defined sub-national level.
§ Five (5) studies (20%) focused on sub-national or regional analysis
 Typology of Needs-Based Model Applications
§ Two types of empirical models were identified:
o Needs-based macrosimulation models: 19 (76%) of the papers included in the review
o Needs-based microsimulation models: 6 (24%) of the included studies.
§ Needs-informed demand models versus complete needs-based models
o There were either complete need-based application or was adjusted with the
currently observed levels of demand for health services (needs-informed demand
models).
§ In the ‘needs-informed demand analysis’ or ‘demand-weighted’ needs-based
analysis, the need for health services was estimated using a measure of
health and demographic variables but in translating into the health
workforce requirements, the estimated need was adjusted by the observed
levels of service utilisation.
Typology of Needs-Based Model Applications
Dimension Needs-based macrosimulation models
Parameters for Used aggregate population-based evidence on the level of
health service need health which included prevalence rates, mortality rates and
risk factors alongside aggregate demographic data
(population size, gender, age etc.) to estimate the
population need for health services, and then translated
into health workforce requirements
Use of patient level No individual patient-level information or assumptions
characteristics were made or required to derive the population need for
health services.
Scope of The analytical applications were almost exclusively broad in
application scope, being either multi-country in nature or covering a
range of disease/program areas in a national or sub-
national health system
Needs-based microsimulation models
used best-practice clinical guidelines
and patient-level attributes – from
routine data, treatment guidelines or
expert opinion to adjust population-
based estimates of diseases prevalence
for deriving the health service needs
which were then translated into health
workforce requirements.
use of patient-level data (or the explicit
assumptions of individual-level
variables) for the derivation of health
service needs
 Synthesis of Key considerations for comprehensive needs-based
health workforce planning

Source: Asamani, J.A.; Christmals, C.D.; Reitsma, G.M. The Needs-Based Health Workforce Planning Method: A Systematic Scoping Review of Analytical
Applications. Health Policy Plan. 2021.
 Advancing the methodology: A model for Needs-based HWF Planning

Source: Asamani, J.A.; Christmals, C.D.; Reitsma, G.M. Advancing the Population Needs-Based Health Workforce Planning Methodology: A Simulation Tool
for Country Application. Int. J. Environ. Res. Public Health 2021, 18, 2113. https://doi.org/10.3390/ijerph18042113
 Tweaks in assumptions
§ Accounting for future changes in level of health: use of instantaneous
rate of change:
o Impact is 17-23% increase in estimated HWF requirements in one applied
example.
§ Including support actvites in the estimation of requirements instead of
supply side
o Nearly 21% additional need in one applied example.
§ Defining Standard Workload:
 Needs-based Health
Workforce Planning Model

Source: Asamani, J.A.; Christmals, C.D.; Reitsma, G.M. Advancing the

Population Needs-Based Health Workforce Planning Methodology: A
Simulation Tool for Country Application. Int. J. Environ. Res. Public Health
2021, 18, 2113. https://doi.org/10.3390/ijerph18042113
Take home messages
§ Needs-based health workforce planning is the conceptually appropriate framework for
Universal Health Coverage
§ There is increasing uptake of the needs-based approach health workforce planning
since 2010, but holistic country-level applications for health workforce policies and
strategies are still limited due to methodological diversity, seeming lack of
standardization and lack of tools.
§ Six broad methodological and process considerations were typical, albeit variations in
how they were implemented across individual models
§ Needs-based HWF models should take account of future changes in population health
status and the support activities undertake by health workers.
§ The time is now to build consensus on how best to support policymakers use needs-
based HWF planning tools.