Projecting Req

PROJECTING
WORKFORCE
REQUIREMENTS:
Planning with the WHO
Scenario Models
Prepared for the World Health Organization
January 2001
Introductory note
This slide show is much too long (~150 slides) to be

shown in one session. As you will see, it has a
number of component parts that can be used
separately, or in multiple sessions, or adapted to
you own circumstances. Give the slide show a
quick scan and decide what parts may be useful,
in what sequence. The major sections are on the
next slide. You can use the search capability to
locate the start of each section.
Workforce Requirements
2
Introductory note
REQUIREMENTS
PROJECTION METHODS
WHO SCENARIO MODELS
WHO REQUIREMENTS MODEL
SUPPLEMENTARY INFORMATION
3
REQUIREMENTS
Objectives
• To measure and project health worker
requirements to a specified target year
– Status quo projection (assumes no major changes
in occupational mix or worker-to-population ratios)
– Baseline projection (assumes continuation of
present and foreseeable trends in expansion,
deployment and use of health workers)
– Alternative projections (assumes projections based
on different assumptions regarding mix, numbers,
and deployment of health personnel to achieve
desired objectives)
4
WHAT IS THE PROBLEM?
Problem identification
• Planning study design, scope and methods
depend on HRH problems that exist or are
anticipated
• Examples of problems that affect projection
method selection and use
– Insufficient or excessive numbers of personnel
– Inadequate quality due to various reasons
– Inappropriate geographic distribution
5
Problem identification
• Additional examples
– Inappropriate functional distribution
– Inappropriate public / private sectoral distribution
– Inappropriate occupational distribution
– Inefficient or inappropriate mix of health workers
– Low productivity due to a variety of reasons
– Excessive or inequitable costs
• This show considers many such problems
6
Problem assessment
• Answers to questions can help set priorities...
– How many people or institutions are affected by the
problem?
– How significant is the problem; how great an impact does
it have on services, etc?
– Does solving this problem depend on solving others first?
– Will solving this problem make it easier to solve other
problems?
7
Problem assessment
• Additional questions...
– How much will it cost to have a effect on the problem?
– How much time is required to have a effect?
– How much support and/or opposition can be anticipated in
addressing this problem?
• Even qualitative answers (eg, many/few, high/low,
much/little) can help you select the planning methods
that will be most useful
8
PROJECTION METHODS
Overview
• Many methods have been used over the years
– Each method has advantages and limitations
• Essential task is to select a method that is..…
– Technically, administratively, economically and politically feasible
– Consistent with available data
– Consistent a country’s health care system, eg…
• Does public or private sector dominate?
• Does government tend to assume an active or passive role regarding how
health sector operation?
9
PROJECTION METHODS
Overview
• If government’s role is active it seeks to shape and control
health system developments, and may also pay a major share
of the costs
– As a result, government is a major determinant of health workforce
requirements
• If government’s role is passive it tries to anticipate health
sector growth and changes
– As a result, government tries to predict events (and hence
requirements) rather than cause them to occur
10
PROJECTION METHODS
Overview
• No government can either completely control,

or be completely passive, toward health
system development
– Therefore, all methods of projecting requirements
must consider both active and passive planning
factors
11
PROJECTION METHODS
Overview
• All requirements projection methods must

convert population into health personnel,
either.....
– Directly, eg, health worker-to-population ratio
method, or
– Indirectly, eg, needs-based, demands-based, or
target-setting methods
12
PROJECTION METHODS
Overview
• Indirect methods go from population to required
services, which are then converted into health
workers by means of productivity norms
• All methods make assumptions about the future
– Since predicting or creating the future is not, and
cannot be, an exact science, no method is free of
error and no method is best for all situations
13
POPULATION RATIO METHOD
• Specify desired worker-to-population ratio(s)
– Often based on current best region ratio or a reference
country with a similar but presumably more developed
health sector
– Project population growth and apply ratio(s)
• Advantages
– Often used, quick, easy to apply and to understand
• Disadvantages
– Desired ratio is often unrealistic; difficult to assess
feasibility; provides no insight into how personnel are used
14
POPULATION RATIO METHOD
• Ratio method is a black box method, that is,
one cannot describe or explore interactions
between numbers, mix, distribution,
productivity and outcomes
– Base year maldistribution will likely continue in
target year
15
EXAMPLE — RATIO METHOD
• Doctor-to-population ratio varies by province
from 1:5000 to 1:2500, with average of 1:4000
– Projected target year population is 10 million
– Desired target year ratio is 1:2500
– Required doctors = 10,000,000 ÷ 2500 = 4000
doctors
16
EXAMPLE — RATIO METHOD
• But, while the target year average ratio may
be 1:2500, provincial ratios may range from
1:1000 to 1:3500
17
NEEDS-BASED METHOD
• Project age- and gender-specific “service
needs” based on service norms and
morbidity trends
• Multiply each projected population segment
by projected service needs for that segment;
combine segment-specific needs to calculate
national needs
• Convert projected service needs to personnel
requirements using productivity norms
18
NEEDS-BASED METHOD
• Advantages
– Logical, consistent with professional ethics,
easy to understand; useful for some programs
such as prenatal and well-child care
• Disadvantages
– Extensive data required; changing technology
requires norm updates; expensive; requires
strong controls over health worker deployment
and health services utilization; likely to project
unattainable service (and hence staff) targets
19
NEEDS-BASED METHOD
• Target: Urban children 0-4 years need an
average of 1.0 doctor visit and 2.0 nurse
visits per year
• Projected target year urban children 0-4

years of age is 2.0 million
20
NEEDS-BASED METHOD
• These children will thus require 2.0 million
doctor visits and 4.0 million nurse visits
• A full-time equivalent doctor attending

young children can provide 6000 visits per
year and a FTE nurse, 7000 visits per year
21
NEEDS-BASED METHOD
• Projected full-time equivalent requirements
are therefore:
– FTE doctors = 2.0 million ÷ 6000 = 333 doctors
– FTE nurses = 4.0 million ÷ 7000 = 571 nurses
22
DEMAND-BASED METHOD
• Measure health service utilization rates
according to age, gender, income, education,
insurance, etc.
• Project population for each “utilization
category” and multiply by observed base year
utilization rates
• Convert projected service demands to
personnel requirements using productivity
norms
23
DEMAND-BASED METHOD
• Advantages
– Economically feasible targets due to no or little
change in population-specific utilization rates;
a defensible logic
• Disadvantages
– Complex; extensive data requirements
– Method produces a “status quo” projection
since future population segments are assumed
to have similar utilization rates as base year
segments
24
EXAMPLE - DEMAND METHOD
• Higher income females living in large cities,
age 15-24 years, use (or “demand”) 1.8 doctor
visits per year while similar lower income
females use 0.7 visits
– Projected target year population for these two
population groups is 200,000 and 800,000,
respectively
– Projected demands:360,000 and 560,000 visits
• 1.8 x 200,000 = 360,000 for higher income females
• 0.7 x 800,000 = 560,000 for lower income females
25
DEMAND-BASED METHOD
• The average doctor working full-time in
ambulatory care can provide 7000 visits per
year
• Target year doctor requirements for visits is

therefore (360,000 + 560,000) ÷ 7000 = 131 FTE
doctors
26
TARGET-SETTING METHOD
• Project population size, characteristics, and
priority service needs and demands
• Set targets for either numbers of services to

produce, or numbers and types of health
facilities and services
• Calculate workforce required to satisfy target

year assumptions
27
TARGET-SETTING METHOD
• Advantages
– Relatively easy; limited data requirements;
understandable; can assess interactions between
variables
• Disadvantages
– Potentially unrealistic assumptions
28
MANAGED CARE METHOD
• Identify an existing health care provider or
system that provides acceptable care at
affordable cost
– This provider or system becomes the “reference
system”
• “Reference” system may be within the country or
another country
• Possible reference systems could come from
social insurance sector, private sector, non-profit
organization, etc.
29
MANAGED CARE METHOD
• Use norms observed in the reference health

system as a basis for future planning. Norms
may be for….
– Numbers, size, distribution, service areas, and
other characteristics of health facilities
– Staff mix, density and productivity for each facility
type
• If necessary, adjust norms to account for
future needs and system improvements
30
WHO SCENARIO MODELS
• The requirements models develop
alternative scenarios of a future health care
system
– Scenarios are different visions of what might
take place based on specified assumptions
– Scenarios are never wrong — they say what
would result if input estimates are valid and
assumptions come true. However...
• Base year data estimates may be wrong
• Planning assumptions may be unrealistic or
impossible
31
WHO SCENARIO MODELS
• Scenario characteristics….
– Scenarios assist planning process by showing
the potential consequences of alternative
assumptions about the future
– Scenarios do not predict the future
– No scenario projection model can result in a
human resources plan!!!
• A plan is the result of human choices
regarding the future evolution of a human
institution, the health system
32
WHO SCENARIO MODELS
• Basic data elements of a requirements projection
– Current active supply of health personnel
– Projected population growth
– Plans, policies and/or trends regarding health sector
development
– Likely patterns of morbidity and service utilization
– Numbers, types, distribution of health facilities
– Staffing and productivity norms
– Assumed public-private sector interactions, that is, what
effects will changes in the public sector have on the
private sector, and vice versa
33
WHO SCENARIO MODELS
• WHO models assume all active health workers are
in one of five locations
– (1) Public sector hospitals (including clinics)
– (2) Public sector ambulatory facilities without beds
– (3) Academic settings (eg, medical schools)
– (4) Non-clinical public health settings (eg, MoH,
provincial public health departments)
– (5) Private sector, divided into two subsectors….
• Independent practice (doctors, dentists, pharmacists)
• Salaried private sector employment (industrial hospitals,
mission hospitals and clinics, private hospitals)
34
WHO SCENARIO MODELS
• WHO models assume health authorities can judge
adequacy of the present health system
– If present health system is satisfactory only minor
changes are necessary to....
• Keep up with population growth
• Further improve quality and quantity of services provided
– If present health system is unsatisfactory, significant
resource changes are necessary to....
• Keep up with population growth
• Improve resource allocation among activities
• Improve resource productivity
• Improve quality of services
35
TWO SETS OF MODELS
• Longer-term (15-30 years) model for
strategic planning
• Intermediate-term (5-15 years) model for

shorter periods
• Models share many features but there are

some differences
36
MODEL FEATURES
• Both models…...
– Accept user-defined scenarios
– Can project to any future year
– Are based on a variant of target-setting method
– Include public and private sectors
– Can easily change inputs and test data “sensitivity”
to error or changed assumptions
– Accommodate 15 (or 20) occupational categories
– Accommodate varying levels of data completeness
and accuracy
37
MODEL FEATURES
• Both models….
– Provide many summary tables that link model
diverse model input and output variables
– Provide many graphic displays of data
– Compare up to nine alternative scenarios for
same health system or geographic area
– Combine projections for different provinces or
health systems to make a national projection
– Have detailed on-line reference notes for each
table
38
-- Comparison --
Long & Intermediate models
• Long HRH model • Intermediate HRH model
– 15 occupations – 20 occupations
– 2 supply methods – 2 supply methods
• Cohort & Loss rate • Loss rate & stock & flow
• File is separate from • File on same spreadsheet
requirements file – 3 requirements methods
– 1 requirements methods • Ratio (to doctors)
• Target (locations) • Target (locations)
– Any duration (20-30 years) • Target (utilization)
– Compare & combine – Any duration (5-15 years)
– 13 utility files to do – Compare & combine
common planning tasks – 19 utility files to do
common planning tasks
39
-- Comparison --
Long & Intermediate models
• Long HRH model • Intermediate HRH model
– Five optional modules – Five optional modules
• Test of economic feasibility • Test of economic feasibility
• Production and utilization of • Production and utilization of
services services
• Urban-rural distribution of • Requirements for public
services health and technician
• Requirements for medical and categories
nursing specialists • Requirements projection for
• Requirements projection for intermediate year, eg, 4
intermediate year, eg, 4 years years after base year
after base year – English version in MS Excel
– English, Spanish & French
versions in run-time module;
English in MS Excel
40
WHO SCENARIO MODELS
• Method used for public sector clinical staff
– Project numbers of hospitals and ambulatory
facilities, by type (acute care, chronic, preventive,
large, small)
– Observe base year population per facility and
distribution of hospital beds; decide whether this is
satisfactory or not
– Maintain or change base year ratio of population-
per-facility to achieve desired balance between
facilities and population.
41
WHO SCENARIO MODELS
• Method of projecting public sector clinical staff
– For example, a country might wish to.....
• Increase the proportion of beds in district hospitals, and
decrease the proportion in tertiary care hospitals
• Improve the health center-to-population ratio faster than
the bed-to-population ratio
• Divide projected population by assumed ratio to determine
number of facilities required
• Assume staffing norms for each facility type
• Multiply target year facilities of each type by staffing norm
to determine clinical staff required
42
WHO SCENARIO MODELS
• Method of projecting public sector clinical

staff
– Divide projected population by assumed facility-to-
population ratio to determine number of facilities
required
– Assume staffing norms for each type of facility
– Multiply target year facilities of each type by
staffing norm to determine clinical staff required
43
WHO SCENARIO MODELS
Example - District Hospital Clinical Staff
• Base year (2000)

– Population = 10 million
– District hospitals = 50
– Population per district hospital = 200,000
– % of all beds in district hospitals = 20%
– General consensus that the average service
area per district hospital is too large, both in
terms of population served and geographic
area covered
44
WHO SCENARIO MODELS
Example - District Hospital Clinical Staff
• Target year (2030)
– Population = 20 million
– District hospitals to have increased share of beds
– Population per district hospital = 100,000
– District hospitals required = 200
– Staff norms require 5 doctors per district hospital
200 hospitals x 5 doctors per hospital =

1000 doctors required for district hospitals
Similar methods used for other facilities

45
• Major data requirements
– Base year population and expected annual %
growth rate for projection period
– Base year health worker supply, by occupation, for
public and private sectors and by major type of
activity (eg, public sector clinical, academic sector,
public health, and private sector)
46
• Major data requirements
– Numbers and characteristics of different types of
public hospitals and clinics; number of private
sector beds
– Assumptions about future mix and distribution of
public sector facilities, staffing norms, & private
sector growth
47
METHODS & ASSUMPTIONS
Base year active supply
• Define occupational categories to be
projected
– Major, large, well-defined categories
– Use conventional, understandable titles
– List categories in a logical order
– Develop master list on paper first, since making
later changes in model may introduce errors
• Estimate active supply to within ±10%
– Registration system, census, sample survey, best
available statistics, etc.
48
Base year active supply
• Estimate full-time equivalent (FTEs)

personnel working in private sector
– Estimate % of all doctor-hours, dentist-hours,
etc., spent in private sector independent practice
and salaried employment
• For example, of all doctor time in country, about what %
of that time is spent in the private sector
– Multiply “% of all hours” by current active supply
to estimate FTEs in private sector
49
Demographic estimates
• Estimate base year population of region

• Estimate annual % population change for....
– First third of planning period
– Second third of planning period
– Last third of planning period
• If population is increasing rapidly, consider
assuming a declining growth rate in later
years
50
Demographic estimates
• Estimate approximate % living in “urban

areas”
– Use a health sector-oriented definition of “urban”
– Assume likely % of urban population in base year
• Project likely % in urban areas in future years
– Usually best to assume an increasing % in urban
areas, eg: If population growth is ~2%, then urban
growth may average 3-4% per year
51
Hospital planning estimates
• Define 5 to 7 different types of public sector

hospitals, for example….
– National, regional, district, chronic disease,
specialized, psychiatric, military, etc.
52
• Estimate base year numbers of each type,

total beds and average bed-occupancy rates
• Review % distribution of beds, by hospital
type
– If satisfactory, assume similar target year
distribution
– If unsatisfactory, change distribution, giving more
or less emphasis to big, medium, or small
hospitals
53
• Review bed-population ratios and bed-

occupancy rates
• Review base year hospital productivity
indices such as bed occupancy rates and
average length of stay
– Assume changes as appropriate
54
Ambulatory care planning estimates
• Define different types of public sector clinics
– Examples include urban polyclinics, health centers
without beds, health posts, MCH centers
– Exclude facilities with beds, eg, health centers with
beds
• Estimate numbers of each type of clinic
55
Ambulatory care planning estimates
• Review % distribution of facilities

– If satisfactory, assume similar target year
distribution
– If unsatisfactory, change distribution, giving more
or less emphasis to different types of facilities
• Review (& change) clinic-to-population ratios
56
Public sector staffing norm assumptions
• Develop average full-time equivalent staffing
norms for each type of hospital and clinic
• Review total staff per facility and staff-bed
ratios to see if they are reasonable
– Larger hospitals tend to have more staff per bed
and higher proportions of specialist staff
– Acute care hospitals have more staff and more
high level staff than long-term care hospitals
– Hospitals tend to have higher proportions of
nursing and technical staff; clinics have higher
proportions of medical and dental staff
57
Private hospital assumptions
• Estimate number of private hospitals and beds
• Assume average annual % change in beds
– Annual % change can be rapid over a short period (<5
years) but will likely be low over a longer period
– Over longer planning period annual % change will
likely average between rate of population growth and
up to 1% above rate of urban population growth, eg,
2.5% population growth, 3.5% urban population
growth, around 4.0% assumed private bed growth
• % change will be higher if government policies favor private
sector, or if government will transfer public beds to private
sector, or if per capita income is increasing rapidly
58
Private sector staffing norm assumptions
• Assumptions will depend on likely long-range
government policies affecting private sector
growth
– Will private sector grow same as, faster or slower than
public sector?
• Assume average annual % change in salaried
staff somewhat above (0.1 - 0.3% more) assumed
annual change in the number of beds
– Small increment assumes staff density, and potential
quality of care, will gradually improve over planning
period
59
Private sector staffing norm assumptions
• Assume average annual % change of

independent practitioners (eg, doctors,
dentists) similar to or somewhat higher (0.1 -
0.3% more) than annual change in urban
population
– For example, if total population is increasing
annually at 2%, and urban population at 3%, and per
capita income is increasing, then independent
practitioners might be assumed to increase at, say,
3.3%
60
Public health personnel
• Public health personnel = persons working in
P.H. programs, administration, and/or P.H.
research and not based in clinical facilities, eg:
– Min. of Health, provincial and district public health
departments, public health programs not based in
hospitals and clinics
– Non-clinical public health personnel typically
account for 2-5% of public sector workforce
• Estimate base year FTE personnel by category
61
Public health personnel
• Assume annual % change over projection

period
– Usually safe to assume an average growth rate
somewhat above population growth rate or, if
economic development is rapid, close to urban
population growth rate
– Increase or decrease individual rates to correct for
likely surpluses or shortages
– Most personnel will be in professional categories
62
Academic personnel
• Estimate base year FTE academic personnel

– Include instructors, administrators and researchers
– Count only academic personnel of the same
discipline as students, eg, doctors teaching medical
students, nurses teaching nursing students
• Estimate enrolled students in each discipline
• Assume average annual % enrolment change
– More than population growth rate if occupation is in
short supply or has high losses (eg, >5-10% per
year)
63
Academic personnel
• Assume target year student-to-instructor ratio
– Consider adequacy of the base year ratio
– Target ratio usually between: 5:1 and 10:1 for higher
level professions (doctors, dentists); 10:1 and 20:1
for technical level occupations (nurses, midwives)
– Increase (improve) nurse:nursing student ratio as
necessary to take into account nurses who train
auxiliary nursing personnel. For example, assume:
• 20 nurse students per FTE nurse instructor; then increase
ratio to 15 nurse students per FTE nurse instructor to take
into account nurses teaching nurse auxiliary students
64
Requirements scenario
• Review numbers and % distribution of
occupations
• Review % distribution among work settings
– Public sector hospitals
– Public sector ambulatory facilities
– Non-clinical public health
– Academic institutions
– Private sector
• Decide whether distributions are reasonable as
basis for later revisions
65
Comparison of supply and requirements
• Project target year supply according to one or
several alternative scenarios
– Differing rates of change of student intakes
– Differing loss rates during training and after
graduation
– Differing gains or losses across provincial or
national borders
– Differing male-to-female student ratios
• Compare supply and requirements projections
– Note shortages or surpluses as basis for later
revisions
66
In summary, to develop a scenario…
• Estimate base year supply of active personnel
• Estimate base year supply of hospitals and

clinics
• Specify public sector population-to-facility

ratios to produce desired target year
availability of facilities
67
In summary, to develop a scenario…
• Multiply target year number of public sector

facilities by target year staffing norms to
obtain staff requirements
• Assume growth rates to calculate staff

required for non-clinical public health,
academic and private sectors
68
REQUIREMENTS METHOD
Advantages
• Can project and compare alternative scenarios

– Alternative growth rates for health sector
– Emphasis on public or private sector growth
– Emphasis on urban or rural services
– Emphasis on acute or chronic services
– Emphasis on curative or preventive services
– Emphasis on higher or intermediate level personnel
69
REQUIREMENTS METHOD
Advantages
• Ability to combine subnational projections
• Combine provincial, state or regional
projections
– Combine projections for different health systems
such as MOH, armed forces, social insurance funds
• Easy sensitivity and economic feasibility tests
– Can determine which data inputs are most
important
– Can set maximum / minimum values and test effects
of input data errors on scenario outputs
70
REQUIREMENTS METHOD
Advantages
• Most core data available from existing sources

• Can manipulate individual sector components
to determine relative impacts on requirements,
costs, and on production and distribution of
services
– Public vs. private sector; hospitals vs. clinics;
different types of hospitals and clinics; different
types of staff
71
REQUIREMENTS METHOD
Advantages
• Can estimate potential production, geographic

distribution and utilization of services,
including per capita availability of services:
– In urban and rural areas
– From public and private sector providers
– From specified types of occupational categories
• Provides many summary tables and graphs to
help interpret results
72
REQUIREMENTS METHOD
Limitations
• Scenario concept is not well understood; users

may expect model to make a plan or forecast
• Model capabilities and versatility make it more
complex, which may reduce use &
understanding
73
REQUIREMENTS METHOD
Limitations
• Recommended projection period (20-30 years)
is longer than is customary in many countries
– Near-term problems make long range planning
difficult
– Limited country experience with trying to maintain
consistent longer term policies
• Use of real (uninflated) funds seems contrary
to reality of rapid inflation that often exists
74
REQUIREMENTS METHOD
Limitations
• Users must make estimates and assumptions
in absence of good historical experience or
field-based data. Troublesome data inputs
concern.....
– Concept of full-time equivalent personnel
– Productivity and geographic distribution
assumptions
– Projected average staffing norms for health facilities
75
SUPPLEMENTARY INFORMATION
The remaining slides provide information
on the following topics
Full-time equivalent personnel
Specifying hospital types
Specifying ambulatory facilities
Specifying occupational categories
Use of index values
Hours worked per year
Clinic productivity
Hospital productivity
Travel time and per capita doctor visits
Typical range values
Distribution problems
Economic feasibility test
Plans and the planning process
Attributes of workforce projections
Strategic planning & length of projections
76
FULL-TIME EQUIVALENT
PERSONNEL
• Schools train people and employers hire
time. Since many doctors and other high
level personnel work part-time for several
employers and in private practice, a means
of converting time into persons is
necessary
• FTEs, also termed WTEs (whole-time
equivalents) make this conversion
– One FTE = two half-time jobs = three third-time
jobs, etc.
77
FULL-TIME EQUIVALENT
PERSONNEL
• Conceptually, a FTE is the total amount of
doctor, nurse, etc, time worked in a country or
region divided by the number of doctors,
nurses, etc., in active practice, eg…
• Practically, a FTE is the usual number of
hours worked per day, eg, 7.5 or 8
– Do not try to count night & weekend “on call” time
for doctors
78
SPECIFY HOSPITAL TYPES
• Develop master list of hospital types on paper

before entering names into computer
– Use a logical order to sequence
– Use names that will be widely understood
– Specify types easily identified from available
hospital data
– Combine types with similar characteristics
79
SPECIFY HOSPITAL TYPES
• Examples of major hospital types include:
– National = 400+ beds, tertiary teaching and referral
– Regional = 200-400 beds, second level referral
– District = 50-200 beds, first level hospital care
– HlthCtre = health center with 5-25 in-patient beds
– Special = specialized services with higher level
staffing norms, eg, infectious, maternity, cancer
hospitals
– Chronic = long-term care with lower staffing norms
– Mental = psychiatric care with lower staffing norms
80
SPECIFYING AMBULATORY
FACILITIES
• Develop master list of ambulatory facility
types on paper before entering names into
computer
– Use a logical order to sequence
– Use names that will be widely understood
– Specify types easily identified from available data
• Include only free-standing facilities that are not satellite
clinics that are part of a hospital’s payroll
– Combine types with similar characteristics
81
SPECIFYING AMBULATORY
FACILITIES
• Examples of major types include:
– Polyclinic = large urban clinic, often with specialty
services
– HlthCntre = health center without beds
– HlthPost = small rural health post
– MCHClin = maternal and child health clinic
– District health teams serving multiple ambulatory
facilities
82
SPECIFYING OCCUPATIONAL
CATEGORIES
• Specify and list categories on paper before
entering them into the model
– List categories in a logical sequence
– Use category names that are widely understood
– Avoid overlapping or unclear categories
– Use no more than two levels per category
• For example, (1) fully qualified and (2) auxiliary and
assistant staff
83
SPECIFYING OCCUPATIONAL
CATEGORIES
– Combine categories that come through a common
pathway
• For example, combine in one category nurses and
midwives if all midwives must first be trained as nurses
• Later, determine what proportion of the nurse category
should be trained as midwives
– Do not include very small categories (<2-3% of
total workforce) or those trained outside of health
sector
• Requirements for such groups can be done manually
84
USE OF INDEX VALUES
• Index values make possible comparison of

values expressed in different units, eg, 10s,
100s, 1000s, 100,000s
• Without index values it is difficult to
determine how, for example, a change in the
doctor supply from 3500 to 4200 compares
with a population change from 12.3 million to
14.1 million
85
USE OF INDEX VALUES
• To use index values…..
– (1) divide target year value by base year value and
multiply result by 100
– (2) set base year value equal to 100
• Example: population increases from 12.3 to 14.1
million, doctors from 3500 to 4200, and hospital
beds from 5300 to 5900; in index values…..
– Population goes from 100 to 115 (up 15%)
– Doctors from 100 to 120 (up 20%)
– Beds from 100 to 111 (up 11%)
86
HOURS WORKED PER YEAR
• Annual work hours usually range from 1500 to
2200 hours
• Annual hours = (days actually worked) x

(average hours per day)
• Typical upper and lower range annual values

are.....
87
HOURS WORKED PER YEAR
– 365 days per year
– Minus 52 to 104 weekend days
– Minus 10 to 30 official holidays
– Minus 10 to 20 annual paid leave days
– Minus 10 to 20 days lost due to illness, injury and
maternity (averaged across occupational category)
– Minus 2 to 5 days in training (varies by occupation)
– Equals 281 to 186 days of actual work days
– Multiplied by 8 to 7 hours actually worked per day
– Equals 2248 to 1302 hours or work per year based on
highest and lowest values
88
CLINIC PRODUCTIVITY
• Patient visits or contacts per health worker per
year can be estimated as follows:
– Total hours actually worked per year (usually 1500-2200
hours)
– Multiplied by % of time actually spent with patients
• Percentage will usually average substantially less than 70%
due to diverse other activities (record keeping, inservice
training, consultation with others, coffee breaks, etc.)
– Equals hours spent with patients
– Multiplied by average patients treated per hour
– Equals patients attended per year
89
CLINIC PRODUCTIVITY
• % of time with patients depends on work location
and occupational category.
– Hospitals: doctors and nurses care for inpatients, clinic
patients, and have non-patient care functions; % time
will range between 20-50% for doctors, and 10-40% for
nurses, with lower values for larger hospitals
– Ambulatory facilities without beds: doctors and nurses
care for patients, have non-patient care functions, and
may spend time in travel; % time attending patients will
average 40-60% for doctors and 30-70% for nurses
90
CLINIC PRODUCTIVITY
• Patients per hour rate varies depending on work
location, type of service, availability of support
personnel, and quality of care
• Assuming a quality service (history,
examination, treatment and instructions), and a
balanced mix of services, average time per
patient might be 6 to 12 minutes, or 10 to 5
patients per hour
– Many countries, however, doctors average 20 or
more patients per hour, too fast for a quality service
91
CLINIC PRODUCTIVITY
• Using reasonable values and assuming efficient
and quality services, average annual FTE doctor
productivities might be….
– Large hospital: 1800 hours per year x 30% with patients
x 7 patients per hour = 3800 patients visits per FTE
doctor
– Small hospital: 1800 hours x 40% with patients x 8
patients per hour = 5800 patients visits per FTE doctor
– Health center / clinic without beds: 1800 hours x 50%
with patients x 10 patients per hour = 9000 patients
visits per doctor
92
HOSPITAL PRODUCTIVITY
Bed-occupancy rate
• Bed-occupancy rate = average % of beds
occupied
• Bed-occupancy = [(Patient-days) ÷ (Beds x
365)] x 100 --- Examples….
– Assume a 200-bed hospital with 58,000 patient-
days = [(58,000) ÷ (200 beds x 365)] x 100 = 79%
occupancy
– Big acute care hospitals should average 85-95%
– Small acute care hospitals should average 65-80%
– Chronic disease hospitals can average 90-95%
93
Bed-occupancy rate
• Factors that may increase occupancy rates

– Large catchment population with good
accessibility
– Inadequate ambulatory care resulting in more
severe illnesses and/or hospitalization for
problems that could be clinic treated
– Inefficient management of diagnostic, treatment,
and/or discharge phases of hospitalization
– Increase % of chronic disease patients
94
Average length of stay
• Average length of stay (ALOS) = average days

per hospital discharge
• ALOS = (Total patient bed-days) ÷

(Discharges)
– Eg: 58,000 bed-days ÷ 8200 discharges = 7.1 days
95
Average length of stay
• Factors that tend to increase ALOS
– Increased hospital ability to treat severe illness
– Reduced % of maternity and other short-term
diagnoses
– Inadequate ambulatory care resulting in more
severe illnesses and/or hospitalization for
problems that could be treated in a clinic
– Inefficient management of diagnostic, treatment,
and/or discharge phases of hospitalization
– Increase % of chronic disease patients
96
Bed-turnover rate
• Bed-turnovers = (Discharges per year) ÷
(Beds)
– Eg: 8200 discharges ÷ 200 beds = 41 bed-turnovers
per year
• Bed-turnovers are a measure of persons
served, on average, by each bed in one year
• Bed-turnovers are end result of the interaction
of all factors that affect bed-occupancy and
average length of stay; they help indicate the
productivity of hospitals
97
TRAVEL TIME & PER CAPITA
DOCTOR VISITS
• Average annual doctor (or other health
worker) visits decline markedly as travel time
(by usual means of transportation) increases.
Per capita annual visits may drop by….
– One-third for persons living one hour away
– One-half for those two hours away
– Two-thirds for those three or more hours away
• Rates can vary widely by country
98
TYPICAL RANGE VALUES
• Health systems, like their host countries and
the people who staff them, vary greatly
• Some variations are within a narrow range
• Typical range values can be useful for those

learning how to use models in absence of
country-specific data
99
• Such values should not be considered
“norms,” since countries may have good
reasons for having values outside of these
ranges
• Data inputs based on these typical ranges for

well managed facilities should be replaced by
country-specific data as soon as feasible!
100
• Range values for large acute care hospitals

– Typically in the capital and other large cities; often
used as national level referral and teaching
hospitals
– 400-1000 beds; 85-95% occupancy; 7-12 days
average stay; 30-40 discharges per bed-year
101
• Range values for medium-sized acute care
hospitals
– Generally in provincial capitals and medium-sized
cities; used as second-level regional facilities
102
• Range values for small acute care hospitals
– Generally in towns and small cities; used as first or
district-level hospitals
– 50-200 beds; 70-80% occupancy; 4-7 days average
stay; 40-60 discharges per bed-year
• Range values for large long-term care hospitals
– Includes mental, tuberculosis, other chronic disease
hospitals with lower staff densities
103
• Prototypical norms for First-Referral
Hospital*
– Demographic profile of community to be served by
hospital and its 15 associated health centers
• 150,000 population
• 6,000 children <1 year (4% of population)
• 30,000 women 15-49 years (20% of population)
• 75,000 children <15 years (15% of population)
*Norms are from World Bank’s “Better Health in Africa” (1994). They are based on African
realities and hence may be lower than those found in other regions.
104
• Prototypical norms for First-Referral
Hospital*
– Requirements
• One building with 140 beds, 4000 square meters of
space, 3 vehicles, blood bank, laboratory
• 3 doctors, 10 nurses, 25 assistant nurses, 3 medical
technicians, 2 management staff, 15 support staff, 2
clerks, for a total of 60 staff or 0.4 staff per bed
105
• Prototypical norms for a Health Center*

– Demographic profile of community to be served
• 10,000 population
• 400 children <1 year (4% of population)
• 2,000 women 15-49 years (20% of population)
• 5,000 children <15 years (50% of population)
*Norms are from World Bank’s “Better Health in Africa” (1994). They are based on
African realities and hence may be lower than those found in other regions.
106
• Prototypical norms for a Health Center*
– Requirements
• One building, no beds, 125 square meters of space, plus
a housing unit for staff, 2 bicycles, one refrigerator
• 1 doctor on visiting basis from District Hospital
Management Team, 1 nurse, 2 assistant nurse/midwives,
1 community service (family planning/nutrition assistant,
1 clerk, for a staff of 5 plus part-time doctor
107
DISTRIBUTION PROBLEMS
Different types of problems
• Identify the type of problem. Is problem.....
– Geographic, eg, urban concentration of health
workers
– Institutional, eg, too many health workers in
hospitals
– Functional, eg, too many surgeons
– Occupational, eg, too many doctors, too few
nurses
– Ethnic or linguistic, eg, too few health workers
available for certain population groups
108
Different types of problems
• Each problem has different causes
– Often several distributional problems co-exist
– This section will focus on geographic, including
ethnic or linguistic, maldistribution
• All countries have unequal geographic
distributions. Key questions are…..
• (1) Whether maldistribution is excessive, and if so
• (2) How can it be reduced?
109
Assessing geographic maldistribution
• Is imbalance large?
• Is imbalance increasing, decreasing, stable?
• Does imbalance significantly impact health
care?
– Access to care
– Quantity of care provided
– Quality of care provided
– Type of services provided
– Continuity of care provided
110
Assessing geographic maldistribution
• Develop urban-rural comparisons regarding.....

– Population per health worker
– Population per hospital bed
– Differential use (per capita) of services
– % of mothers and children receiving basic care
– Average travel time to obtain services
– % of rural residents using urban facilities for primary
care
• Survey urban clinics to determine patient origins and reasons
for seeking care
111
Analysis of past and current policies
• Examples of policies that may have been

applied.....
– Rural service required for licensure
– Preferential rural post salaries and benefits
– No public sector jobs without prior rural service
– Preferential training opportunities for rural residents
– Public recognition for rural service
112
Analysis of past & current policies
• What have been effects of these policies?

– Has implementation been consistent? Sustained?
• If not, why, and what can be learned from these problems?
– Are incentives & disincentives enough to affect
behaviors?
– Have policies been evaluated?
– Can any changes be attributed to these policies?
113
ECONOMIC FEASIBILITY TEST
• This test measures likely public sector economic
feasibility of a supply or requirements scenario
• Test is based on real (uninflated) national
currency
– Inflation is not considered since it is not predictable
– Underlying assumption is that over time, government
will adjust public sector salaries for inflation to
maintain approximate buying power of currency
114
• Test uses recurrent expenditures and does not
include capital investments
– Recurrent expenditures include personnel,
equipment, drugs, vehicles, supplies, fuel, power,
communications, etc.
– Capital investments vary widely from year to year,
and accounting is complicated by long-term loan
paybacks
115
• Since test is a measure of relative change in
the economic burden it is not necessary to
use precise estimates of incomes and
expenditures
– Test does not depend on absolute money values
spent in base and target years!
116
• Underlying assumptions are that over time.....
– Total staff on public sector payroll will increase
– Annual public sector staff expenditures will
increase
– Average uninflated public sector salaries will
increase
• Real salaries may decrease during some periods but if
there is any per capita economic growth at all, government
will try to increase real salaries over the long run
117
Example of feasibility test
• Base year public sector estimates
– FTE supply = 1000 doctors and 2000 nurses

– Average annual FTE salaries of $2000 and $1000
– Salary costs = $2.0M for doctors and $2.0M for
nurses, or $4.0 million total for both occupations
118
• Target year public sector scenario
– FTE requirements = 2000 doctors, 5000 nurses
– Annual FTE salaries increase an average of 1% per year
or 35% over 30 years, resulting in average salaries of
1.35 x $2000 = $2700 for doctors, and 1.35 x $1000 =
$1350 for nurses
– Salary costs = [(2000 x $2700) + (5000 x $1350)] = $12.2
million
– T-Y / B-Y = 12.2 ÷ 4.0 = 3.05, meaning that salary costs
have increased over threefold
• In index values, salary costs have risen from 100 to 305
119
• If public sector funds available to pay salary costs
increase over 30 years at.....
– 3% per year, available funds will increase 143% for an
index value of 243, which is well below the calculated 305
index value for salary costs
– 4% per year, available funds increase 224% for an index
value of 324, which is slightly above the calculated 305
value for salary costs
• Conclusion: public sector funds must increase an
average of almost 4% per year to cover projected
salary costs
120
Comment and critique
• Since test is based on rate of change in

relative values you can use either
– (1) actual incomes or
– (2) an assumed income such that the lowest
occupational category gets an arbitrary 100 or 1000
currency units per year
121
• Since most projections involve a changing mix

of health workers, make reasonably accurate
estimates of relative incomes
– For example, assign 100 to lowest average annual
salary and set other salaries in relation to that.
Thus, if auxiliaries earn 100, nurses might earn 170,
dentists 290, and doctors, 310, etc.
• Cost projections have no value whatsoever for
projecting actual expenditures
122
• The average difference between the economic
and population growth rates determines funds
available to improve standard of living
• Additional public sector funds can be used to.....
– Increase staffing densities, eg, more staff per bed
– Increase % of qualified, and more expensive, staff
– Increase real staff salaries
– Allocate relatively more or less money to recurrent
personnel, non-personnel or capital investment
123
• Annual real increase in public sector funds

available for health personnel over an
extended period will probably average
between 1% less than, and 2% greater than,
projected rate of growth of gross domestic
product, eg:
– If average annual GDP increase is 5%, public sector
funds for personnel are likely to increase at 4-6%
per year
124
• Factors tending to increase expenditures on

health personnel
– As economic development progresses most
countries tend to increase % spent on health
– Rapid urbanization (urban population has more
money & education, & demands more expensive
health care)
125
• Factors tending to increase expenditures on

health personnel
– Government policies promoting public health
sector growth and/or allocating relatively more to
personnel as compared with non-personnel budget
items
– Opposite factors tend to decrease health sector
growth
126
PLANS AND THE
PLANNING PROCESS
Converting plans to policies to action
• Plan implementation is often disappointing

due to insufficient attention to how the plan is
developed, that is, the planning process
• To increase chances of implementation, one
must consider many factors of a fiscal,
technical, administrative, and political nature
– These must be addressed throughout the planning
process
127
PLANS AND THE
PLANNING PROCESS
• At beginning of planning process, consider

certain key questions
– Determine how each question should be answered
for your country and planning situation
– Use answers to guide how planning effort should
proceed — who should be involved, how, when,
and why?
128
PLANS AND THE
PLANNING PROCESS
• Will the ultimate attainment of plan

objectives.....
– Be technically easy or difficult
– Be administratively easy or difficult
– Be politically easy or difficult
– Require small or large expenditures
– Require a short or long time to achieve
129
PLANS AND THE
PLANNING PROCESS
• Will ultimate attainment of plan objectives.....

– Require few or many changes, by few or many
groups
– Require small or large behavioral changes
– Require small or large attitudinal changes
– Require few or many persons for their
implementation
– Require little or much involvement of the general
public
130
PLANS AND THE
PLANNING PROCESS

– Require little or much prior education of affected
parties
– Have a high or low probability of success
– Have a low or high risk of bad consequences if
unsuccessful
– Make it easier or more difficult to attain other
objectives
131
PLANS AND THE
PLANNING PROCESS

– Affect primarily the public or private sector
– Have strong or weak support from important
groups
– Have weak or strong opposition from important
groups
– Involve collection and use of uncontroversial or
controversial information
132
PLANS AND THE
PLANNING PROCESS
• Each of these questions is a continuum,
extending from easy to difficult, low cost to
high cost, rapid to slow
– The more answers are toward the first alternative,
the easier planning and policy implementation will
be
– If many answers are toward the second alternative,
the planning process must give special attention to
gaining acceptance by those who will be most
affected by change
133
ATTRIBUTES OF PROJECTIONS
• Do not apologize for making assumptions!

– Nobody can predict the longer-term future of a
complex human-based organization such as health
services
• Political and social uncertainties
• Economic and demographic uncertainties
• Health risk and health technology uncertainties
• Health system and workforce uncertainties
134
• But, short-term HRH projections are of no

value for planning training institution capacity,
orientation and enrolments
– Training program outputs cannot change quickly
– Changed outputs are slow to affect supply
135
• All projection methods, without exception, must
make assumptions about the future
– Most base year and historical estimates are not precise
– “Easy” projection methods (eg, population-to-
personnel ratios) make huge simplifying assumptions
that cannot be examined or challenged since they are
not stated
– “Complex” projection methods (eg, needs-based,
demand-based methods) require extensive data and
require many, many assumptions
136
• The true test of a projection method is not whether it
predicts the future, an impossibility
– A successful planning method helps decisionmakers
select from among alternative visions of the future
• To travel to a distant destination you need to know (1) your
eventual destination, and (2) in which direction to start
• The models help answer both questions — about where you want
to go, and how to get started
• The models cannot provide detailed route guidance for the middle
and final part of the journey
– Successful planning reduces the need for abrupt policy
changes
137
• Good planning seeks gradual changes,
making it easier to....
– ....gain broad acceptance of change
– ....anticipate resource requirements
• Bad (or no) planning often results in abrupt,
crisis-induced changes, which contribute to....
– ....political, social and professional conflict
– ....imbalances between resources and programs
138
STRATEGIC PLANNING
• Strategic workforce planning seeks to
provide future administrators with a
reasonable mix and numbers of health
workers to staff the future health system
– “Reasonable” is based on anticipated policies,
needs and funds
– Even with good planning, most occupational
categories will be in surplus in some years and
shortage in others due to market fluctuations
139
STRATEGIC PLANNING
• The current workforce size and
characteristics are the result of many
decisions taken over the last 40 years
– Managers must adjust to these realities even
though staff numbers and characteristics are
often inappropriate to current program needs
• Strategic workforce planning cannot
anticipate precisely how the future workforce
will be deployed
140
STRATEGIC PLANNING
• Strategic planning requires long-term
projections (10-30 years)
• One can ask why make such projections
since.....
– Planning variables often vary significantly from
year to year?
– Governments can seldom assure long-term
policy continuity?
141
STRATEGIC PLANNING
• Long-term projections are required due to delays
between actions and effects. For example:
– A 50% change in medical student intake changes
doctor supply only ~10% in first 10 years
– Major changes in health facility capacity, mix, and/or
staffing norms take years to accomplish so short- term
scenarios offer little chance to explore the effects of
innovation
– Only longer projections can reveal potential harmful
consequences of major policy options
142
STRATEGIC PLANNING
• Workforce planning has often been of limited
value in the past due to multiple reasons….
– Inappropriate, inadequate and/or inflexible
planning methods
– Too much attention to quantitative aspects, too
little to qualitative and productivity aspects
– Too much attention to supply, too little to
requirements
• A chain (of logic) is only as strong as its weakest link
143
STRATEGIC PLANNING
• Additional historical reasons for limited
value of workforce planning….
– Insufficient attention to implementation
– Often episodic and motivated by crises
– Much planning has not been part of a regular
planning cycle
– Little attention to testing economic feasibility
144
STRATEGIC PLANNING
– Plan preparation has tended to take too much
time (2 to 4 years)
– Governments and policymakers change, data
become out of date, interest in planning declines
– Data collection often inappropriate or not useful
to key policy questions
– Inadequate attention to political aspects
145
STRATEGIC PLANNING
– Inadequate attention to monitoring progress and
updating projections and policies
– Insufficient involvement of policymakers and
major interest groups in process aspects of
planning
146
STRATEGIC PLANNING
• Workforce planning will likely be of greater
value in the future due to….
– Increased economic pressures on health sector
• Slow growth in Africa, recent economic crises in Asia
• Structural adjustment programs
• Private sector appeal, promotion, competition
– Lending institution insistence on planning
• Pre-project planning work; extensive technical
assistance
• Specification of targets, monitoring and evaluation
147
STRATEGIC PLANNING
– More severe consequences of bad decisions
• In past, little accountability for effects
• In past, no alternative health providers other than the
public sector for most people
– Increasing computer hardware and software
capabilities
• Desktop PCs have near-mainframe capabilities
• Much more user-friendly software
148
STRATEGIC PLANNING
– Better planning methods & tools
• Simulation and modeling
• Rapid survey and sampling techniques
• Survey & data collection instruments
• Manuals, how-to books, programs by WHO,
governments, consulting firms
• Rapid increases in computer capabilities
• Greater appreciation of need for all parties to participate
in the planning process
149
Addendum
This MS Powerpoint slide show was prepared for the World Health
Organization by Thomas L. Hall, MD, DrPH (Dept. of Epidemiology and
Biostatistics, Univ. of California School of Medicine, 500 Parnassus,
MU425W, San Francisco, California 94143, USA). The show is part of a
larger set of slide shows made available by WHO to assist planners,
educators, and health system managers in their presentations and
teaching activities relevant to human resources development. Please
send suggestions for improvement of this show (or a file containing the
improved show), or other shows of potential use in HRD to WHO (Dept. of
Organization of Health Services Delivery,1211 Geneva 27, Switzerland,
and to T.L. Hall at the above address or by e-mail to: thall@epi.ucsf.edu.
You are welcome to modify this show, change the formatting, or translate
this show in accord with your own needs and circumstances.
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PROJECTING

Prepared for the World Health Organization

This slide show is much too long (~150 slides) to be

• No government can either completely control,

• All requirements projection methods must

• Projected target year urban children 0-4

• A full-time equivalent doctor attending

• Target year doctor requirements for visits is

• Set targets for either numbers of services to

• Calculate workforce required to satisfy target

• Use norms observed in the reference health

• Intermediate-term (5-15 years) model for

• Models share many features but there are

• Method of projecting public sector clinical

• Base year (2000)

200 hospitals x 5 doctors per hospital =

Similar methods used for other facilities

• Estimate full-time equivalent (FTEs)

• Estimate base year population of region

• Estimate approximate % living in “urban

• Define 5 to 7 different types of public sector

• Estimate base year numbers of each type,

• Review bed-population ratios and bed-

• Review % distribution of facilities

• Assume average annual % change of

• Assume annual % change over projection

• Estimate base year FTE academic personnel

• Estimate base year supply of active personnel

• Estimate base year supply of hospitals and

• Specify public sector population-to-facility

• Multiply target year number of public sector

• Assume growth rates to calculate staff

• Can project and compare alternative scenarios

• Most core data available from existing sources

• Can estimate potential production, geographic

• Scenario concept is not well understood; users

• Develop master list of hospital types on paper

• Index values make possible comparison of

• Annual hours = (days actually worked) x

• Typical upper and lower range annual values

• Factors that may increase occupancy rates

• Average length of stay (ALOS) = average days

• ALOS = (Total patient bed-days) ÷

• Some variations are within a narrow range

• Typical range values can be useful for those

• Data inputs based on these typical ranges for

• Range values for large acute care hospitals

• Prototypical norms for a Health Center*

• Develop urban-rural comparisons regarding.....

• Examples of policies that may have been

• What have been effects of these policies?

• Base year public sector estimates

– FTE supply = 1000 doctors and 2000 nurses

• Since test is based on rate of change in

• Since most projections involve a changing mix

• Annual real increase in public sector funds

• Factors tending to increase expenditures on

• Factors tending to increase expenditures on

• Plan implementation is often disappointing

• At beginning of planning process, consider

• Will the ultimate attainment of plan

• Will ultimate attainment of plan objectives.....

• Will ultimate attainment of plan objectives.....