Health workers are essential to population health. This paper addresses needed global and country-level action to build human resources for health data, systems and impact measurement. Using a conceptual framework drawn from theories on political prioritization (Shiffman 2007) and public mandates as mechanisms for reform (Kingdon 1984), we argue that increasing global health needs are driving political action to develop human resources for health data and measurement systems. To assess the evidence of past calls for health workforce data measurement, we conducted a systematic review of documents published between 2000 and 2014, searching for evidence of explicit calls for building health workforce data and measurement systems. Sources of evidence include World Health Assembly Resolutions and documents and events generated by key stakeholders: global organizations, civil society, donors, non-governmental organizations and professional organizations. We found that few World Health Resolutions contain specific language that addresses human resources data or systems. Stakeholder documents, however, contain more evidence of calls to expand health worker data systems.

The Sustainable Development Goals, national commitments to implement universal health coverage and efforts to increase the health workforce and strengthen global governance and accountability are recent initiatives with potential to improve access to health services. We posit that the temporal convergence of these initiatives is opening a window that will accelerate global and country-level receptivity and action to improve health workforce data and impact measurement necessary to build better health systems and improve population health.  

Urgent Need for Health Workforce Data

Efforts to improve global health continue to draw needed attention to health systems strengthening (HHS) and human resources for health (HRH). The urgency to grow and retain a competent and supported health workforce, the backbone of health systems, in low-, middle- and high-income settings is even more pressing, given the increasing prevalence of non-communicable diseases, devastating outbreaks of infectious diseases and calls for democratization of access to health services through universal health coverage (UHC) and equity. These factors, together with the expanding provision of health services by the private sector in low-and middle-income countries (LMICs) and pressure for transparency, are fueling the demand for HRH data that are: (1) reliable; (2) efficient to collect; (3) frequently updated; (4) inclusive across cadres and settings; and 5) supported by inter-operable, open-source information systems. 

In 2014, on the heels of the 2013 Third Global Forum on HRH in Recife, UN member states and the WHO charged the Global Health Workforce Alliance (GHWA) to lead an inclusive consultative process to draft recommendations for a Global Strategy for Human Resources for Health to be presented to UN member states at the 69th Session of the World Health Assembly (WHA) in May 2016 (WHA 2014). The evidence reported here was generated as part of a review for the Global Strategy consultation process by several members of Technical Working Group 3 (TWG3 2015). 

Since 2000, resolutions of UN member states and the WHA, reports and initiatives of the WHO, and advocacy by global, regional and country-level stakeholders document the need to grow and retain adequate numbers of competent and motivated health workers  (AAAH 2012; WHOAfro 2005; AHWO 2010; APHRH 2011; CfWI 2010; Chan et al. 2010; DeLuca and Soucat 2013; FHWC 2012; G8 2008, 2011; GHWA 2010a, 2011b, 2012c; H8 2010; Middleberg 2010; Ottersen et al. 2014; Scheffler et al. 2009; Spero et al. 2011; Speybroeck et al. 2006; UN 2000, 2001a, 2010b; WHO 2006, 2008d, 2010d, 2012a) . Yet, despite the glaring shortage of health workers in LMICs, and real, but less severe shortages across high-income countries, calls for and development and implementation of HRH data systems and related impact measurement have been markedly lacking. Defining the 2000 United Nations Millennium Development Declaration on Millennium Development Goals (MDGs) (UN 2000) as the starting point for analysis, we conducted a systematic review for evidence that addressed the need for HRH data systems and impact measurement found in documents from 2000 through 2014 and categorized that evidence across nine themes. Sources include WHA Resolutions (WHA 2000-2014) and documents and activities of key stakeholders: global organizations; advocacy groups; civil society; donors; non-governmental organizations (NGOs); and professional organizations. 

The lack of reliable and current HRH data is problematic in health service delivery, education and training, strategic planning and organizing health workforce responses to emergencies. In addition to healthcare service provision, HRH data are necessary to evaluate health system investments, efficacy and population health needs. Despite numerous calls, UN member states and stakeholders have been slow to act on HRH data as a political priority. Indeed, the lack of timely and accurate HRH data and the availability of interoperative data systems are the most limiting factors in projecting, managing and evaluating country-level and global health workforces. While technological capacity, connectivity and big data management have advanced in other sectors, health systems across all income settings lag behind sectors such as finance and manufacturing in the use of data systems. The health sector’s lag in use of HRH data constrains its capacity to plan and project stock, evaluate competency, measure productivity and evaluate health workforce in the context of health outcome and impact metrics (ITU 2013; Jamison et al. 2013; Paris21 2000; WHO 2008c, 2011a, 2012d, 2013a, 2013b, 2014a). 

Attention to changing demographics, increasing prevalence of chronic health conditions, ubiquitous outbreaks of communicable diseases and focus on prevention, measurement and outcomes research are escalating the need to accelerate improved governance and accountability for HRH data systems that serve local, national, regional and global health needs. 

Framework 

Political agenda setting and public policy are complex processes that require a number of inter-connected conditions. The conditions can exist when: (1) national political leaders express sustained concern for an issue (Shiffman 2007); (2) the government enacts policies and strategies to address the problem; and (3) the government allocates adequate budgets to support the issue (Ibid). Kingdon (1984) suggests that receptiveness for major policy change depends on the presence of a strong public mandate. Building off these constructs, we posit that the increasing focus on the health workforce from 2000 through 2014 generated global and national policy imperatives to develop and implement HRH data, systems and impact measurement. Shiffman’s and Kingdon’s perspectives underpin our conceptual framework: increased focus on HRH has capacity to generate policy imperatives that advance global governance and national accountability for national, regional and global HRH data, systems and impact measurement. 

Questions that underpin the study are: 

Question 1: What influence has the focus on the health workforce between 2000 to 2014 had on generating policy imperatives at global and national levels to (a) develop, collect, report and utilize HRH data; (b) build HRH data systems; and (c) use these data in impact measurement? 

Question 2: Will the convergence of the 2015 MGD target dates, setting forth the SDGs and post-2015 agenda and global consensus in support of UHC and equity, drive policy imperatives to develop and implement global and national HRH data systems and impact measurement? 

Proposition 1: The increasing frequency and volume of evidence focused on the global health workforce found in multiple sources from 2000 to 2014 is fostering national and global entities to build local, national and global information systems to capture, store and generate HRH data and develop impact measures. 

Proposition 2: The convergence of the 2015 MGD target dates and post-2015 agenda and global consensus in support of UHC and equity is generating robust policy mandates among global national and global stakeholders to develop and implement HRH data, systems and impact measurement. 

Methods

We conducted a systematic review and process tracing for evidence that calls for HRH data measurement and categorized the evidence found in source documents, donor reports, interviews and focusing events generated by (1) the WHA and (2) key stakeholders: global organizations, civil society, donors, NGOs and professional organizations. The stakeholder evidence reviewed represents a select sampling and is not inclusive of all stakeholder documents and activities. 

Consistent with the consultative process used in developing the Global Strategy on HRH, we utilize the same eight themes in the health labour market framework outlined by Sousa and colleagues (2013, 893, Figure 1) along with one additional category, “other enablers, research”, to categorize the themes contained in the WHA Resolutions. We categorized the actions described in the WHA HRH-related resolutions and stakeholder documents among one or more of the following themes: (1) demand; (2) supply, education; (3) data, measurement; (4) accountability, alignment post-2015; (5) leadership, governance, policy alignment; (6) supply, demand/fragile states; (7) productivity, performance; (8) supply non-professionals; and (9) other enablers, research. Explicit calls for data and measurement are defined here as language that addresses health workforce data and/or measurement. Implicit calls for data are defined here as language that suggests or implies that data are needed to assess or report on activities or programs. 

Findings: Evidence 2000–2014

WHA Resolutions

The review of WHA Resolutions generated between 2000 and 2014 reveals an increasing frequency of recommendations that call for strengthening the health workforce (WHA 2000–2014) (Figure 1). During this period, WHO member states generated 374 WHA Resolutions. Of the total number of Resolutions, 209 are categorized as health-related in nature and are further analyzed. The 165 non-health resolutions, categorized as financial and/or regulatory in nature, were excluded from further analysis.

Figure 1. Stakeholder evidence: documents and events by year

 

Of the 209 health Resolutions, 109 (52%) relate, at least in part, to HRH and associated action(s) in one or more of the nine themes described. The most frequent themes of the WHA Resolutions are theme 5, leadership, governance, policy alignment (26%), followed by theme 2, supply/education (24%), and theme 7, productivity performance (16%). theme 3, data and measurement, represented 4% of the total themes addressed (Table 1). 

While a majority of the 209 health resolutions includes language and references to health workforce, explicit language and evidence calling for the development of HRH data, systems and impact measurement are sparse. Further, of the 109 health/HRH resolutions, only seven address explicit actions related to HRH data, systems and impact measurement, reflecting the low presence that HRH metrics occupied in the global policy architecture of the WHO. 

Over the examined period, there is a notable trend from 2005 through 2014, as the number of resolutions with HRH actions markedly increased (2005, 2007, 2010, 2011 and 2014) (Figure 1). However, despite the period between 2000 through 2014 being marked by HRH “crises” and “scale-up” activities, recognition of the centrality of health workers, and urgency to strengthen health systems, specific WHA Resolutions focused on health workforce data and measurement are remarkably few in number. And, while effective implementation and evaluation of most health and the HRH-related resolutions implicitly rely on the availability of HRH data, explicit evidence in support of implementing and use of data, systems and impact measurement is sparse. The lack of explicit calls for HRH data suggests that a concerted, global movement for health workforce measurement systems would be impactful.  

Table 1. Sample WHA resolutions by theme, order of frequency and extract/action

Theme WHA resolution (yr) Extract/action
(5) Leadership, governance, policy alignment 
55.11 (2002) 
67.14 (2014) 
“3) to accelerate development of an action plan to address the ethical recruitment and distribution of skilled health-care personnel, and the need for sound national policies and strategies for the training and management of human resources for health;” “9) to adopt policies that create healthy workplaces, protect workers’ health and, consistent with national and international law, prevent transfer of hazardous equipment, processes and materials;” 
“11) to emphasize the importance of strengthening health systems, including the six building blocks of a health system (service delivery; health workforce; information; medical products, vaccines and technologies; financing; governance and leadership), to progress towards and sustain universal health coverage and improved health outcomes;” 
(2) Supply, education 62.12 (2009) “5) to train and retain adequate numbers of health workers, with appropriate skill mix, including primary care nurses, midwives, allied health professionals and family physicians, able to work in a multidisciplinary context, in cooperation with non-professional community health workers in order to respond effectively to people’s health needs;” 
(7) Productivity, performance 55.12 (2002) “6) to build and strengthen partnerships between health-care providers, both public and private, and communities, including nongovernmental organizations, in order to mobilize and empower communities in the response to HIV/AIDS;”
(9) Other enablers, research 
55.23 (2002) 
60.27 (2007) 
“3) to monitor scientific data and to support research in a broad spectrum of related areas, including human genetics, nutrition and diet, matters of particular concern to women, and development of human resources for health;” 
“6) to strengthen the capacity of health workers to collect accurate and relevant health information;” 
(1) Demand  56.6 (2003)  “2) to strengthen human resource capability for primary healthcare in order to tackle the rising burdens of health conditions;” 
(3) Data, measurement  59.27 (2006)  “5) to provide support for the collection and use of nursing and midwifery core data as part of national health-information systems;”

 

Stakeholders

The focus of stakeholders – global organizations, civil society, donors, NGOs and professional organizations – on the global health workforce steadily increased over the period studied (Figure 2). Evidence includes the WHO and GHWA reports, documents and events generated by other stakeholders, namely, civil society, donors, NGOs and professional organizations. 

Figure 2. WHA health/HRH resolutions by year

 

There is a notable increase in the generation of health and HRH associated evidence by stakeholders from 2008 through 2014 with 2008, 2010, 2011, 2013 and 2014 showing spikes in activity. Generation of health and HRH-associated evidence accelerated from 2008 through 2014. The most frequent themes addressed in the stakeholder evidence are: 5) leadership, governance (14.5%); 2) supply, education (13.4%); 7) productivity, performance (13%); 1) demand (12.7%), and 6) supply, demand, fragile states (12.7%). theme 3, data and measurement, accounted for only 5.56% of stakeholder evidence. 

Interestingly, the several stakeholder spike years temporally align with WHA resolution spike years. And, years 2005, 2007, 2008, 2012 and 2013 follow and/or are followed by one or more major global HRH initiatives: World Health Report (2006); creation of the GHWA (2006); 1st Global Forum on HRH and Kampala Declaration, Agenda for Global Action (GHWA 2008); UN consensus statement on UHC (UN 2012) and Recife Declaration (GHWA 2013c); and Global Strategy on HRH (WHA 2014). These temporal associations between HRH-related WHA Resolutions, stakeholder evidence on HRH data and major global HRH initiatives suggest multi-directional relationships across actors (see Appendix A and Appendix B). 

Of the explicit HRH data evidence, civil society, a constant advocate for growing HRH and the need for workforce data systems, generated the major proportion of the evidence (Capacity Plus 2014; Center for Global Development 2014; DeLuca and Soucat 2013; FHWC 2014; GHWA 2013b [Stakeholder Commitments]; HWAI 2014; IOM 2009; Health Metrics Network 2011; Soucat and Scheffler 2013; Sousa et al. 2013), followed by GHWA (21%) (GHWA 2010b, 2011a, 2013a, 2013b [53 Country Commitments], 2014) and the WHO (21%) (2000, 2006a, 2007, 20011d, 2011e). Established in 2006, the GHWA convened three global meetings on HRH during the study period. Third Global Forum on HRH held in Recife in 2013 elicited numerous commitments on HRH from 53 member states and 27 other constituencies (GHWA 2013b). Solicited to accelerate progress on the global HRH agenda and the essential role of the health workforce to attain MDGs targets, implement UHC and post-2015 health development priorities, many of the commitments address HRH data systems implicitly and/or explicitly. 

Donors supported seminal initiatives that addressed health workforce issues (JLI 2004) and continue to provide needed resources to advance HRH. Donor stakeholders generated 8 of 67 sources of the evidence on HRH (Global Fund 2008; OGAC 2003, 2008, 2012; JLI 2004) and Reports of Ministries (Omaswa and Boufford 2010; US GHI 2009; World Bank 2014). NGOs have been constant advocates for the health workforce and generated a significant portion of the evidence. Among professions, nurses and midwives stand apart in their advocacy to build and monitor HRH data. The evidence includes the Report of the State of Midwifery (UNFPA 2014), a Recife Commitment by International Confederation of Midwives (ICM) and the International Council of Nurses (ICN) (GHWA 2013b) and the Triad Communiqué (2014) by government chief nursing officers, midwifery officers, representatives of national nursing organizations and regulatory bodies (Table 2). 

Table 2. Sample stakeholder evidence by frequency of theme and extract/action

Theme Source/year Extract/action
5) Leadership, governance, policy alignment 
Joint Learning Initiative (JLI), 2004 
p 137 “Effective action, both urgent and sustained, requires solid information, reliable analyses, and a firm knowledge base. But data, analyses, and research on human resources for health and technical expertise are underdeveloped, in part due to chronic underinvestment. National and global learning processes must be launched to rapidly build the knowledge base – essential for guiding, accelerating, and improving action. A culture of science-based knowledge building must be infused into the human resources community.” 
(2) Supply, education Soucat and Scheffler, 2013, The Labor Market for Health Workers in Africa  p 12 “Overall we know very little of the supply and distribution of health workers in Africa The information deficit is staggering...A major investment is required to generate the evidence needed to support effective policies.”
(7) Productivity, performance UNFPA, et al., State of Midwifery Report 2014  p 41 “Every country needs a minimum HRH data set on their midwifery workforce...this includes headcount;...” 
(1) Demand 
GHWA, 2013 Third Global Forum HRH, Recife 

“14, ii enhance HRH information systems to facilitate labour market analysis in HRH forecasting and link needs-based planning and projections to innovative practices;” 

“18. We commit to addressing transnational issues and work towards strengthening health systems, including global HRH governance and mechanisms, by: (i) disseminating good practices and evidence; (ii) strengthening data collection from all countries...” 

6) Supply, demand fragile states  GHWA, 2010, HRH: Country Coordination & Facilitation  p 10 “It is also imperative that monitoring of HRH programmes of partners complies with the national HRH plan, strengthens human resources information systems and involves the national health workforce observatories.” 
3) Data and measurement  Frontline Health Workers Coalition, 2014, A Commitment to Community Health Workers  P 10 “Create a minimum data set on CHW enabling governments to make evidence-based decisions...“; “Create national registries and integrate them into the nation human resources information system.”

 

One study limitation is the sampling of stakeholder sources, which is not inclusive of all sources of HRH data evidence generated by stakeholders. In addition, we limited our review to major global HRH sources and did not review national documents due to resource and time constraints.  

 Conclusions and Opportunities 

  1. The evidence is striking for what is not included, notably the sparse language in WHA Resolutions that explicitly calls for development of HRH data/ systems and their use in health impact measurement. This finding heightens the need for effective global governance mechanisms to foster expansion and utility of health workforce data. 
  2. The approaching MDG target dates, adoption of the Sustainable Development Goals (SDGs) and the post-2015 agenda appear to be contributing to a mandate on HRH data measurement. 
  3. A cross-section of global, national and local leaders and stakeholders recognize the inconsistencies and gaps in HRH data reporting from member states and call for actions to improvement in the quantity, quality and frequency of HRH data and impact metrics. 
  4. Progress in information technology and systems, and the movement for big data across sectors, including health, are adding fuel to the argument for improved and frequent national HRH data to assess health impact measurements. 
  5. Improvements and innovations in the use of information systems and connectivity in low- and middle-income settings enable health data exchange and health information systems; however, they require resources and a number of inputs and conditions. 
  6. Changing demographics, increasing prevalence of chronic health conditions, focus on prevention and measurement and outcomes research are coalescing and advancing policy imperatives for data systems to assist local, national and global entities assess, plan and evaluate the health workforce. 

Recommendations 

Convergence of 2015 MDG target dates, adoption of the Sustainable Development Goals (SDGs) and post-2015 agenda and population health needs are driving a growing global mandate, opening a window for global and national actions for health workforce data, systems and impact measurement. 

The evidence described suggests that all stakeholders increased the frequency of and calls for HRH data measurement over the time period studied. The following actions have potential to actualize health workforce data systems going forward: 

  1. Global governance and leadership by UN member states, WHO and stakeholders are essential to advance national and global HRH data and systems development. Ongoing consultation with interest groups and stakeholders is key to member state engagement and future adoption of HRH data. 
  2. National governments have a responsibility to invest in HRH data systems. Countries should identify local HRH data champions and, with multi-sectoral and multi-stakeholder engagement, build national HRH data centres for HRH data, systems and impact measurement. 
  3. Investments by national governments, global organizations and donors are needed to develop and implement HRH data, systems and impact measurement. Private-sector donor support can accelerate rapid development and implementation of HRH data systems. Needed resources go beyond fiscal capacity and include infrastructure and human resource support for training and ongoing technical support. The expanding corporate sector development in LMICs presents opportunities for them to invest in national health systems. 
  4. Leadership and oversight to develop and implement global and country-level HRH data programs should be placed with an appropriate entity such as the GHWA or a new multi-sectoral, multi-stakeholder entity sufficiently empowered and resourced. This entity would work with regional and national HRH data observatories and engage key stakeholders and sectors. 
  5. Establish regional support structures or observatories for HRH data systems and impact measurement, which will provide data management and technical support to ensure reliability of data. Functions would include support and systems enhancement for data efficiency, security and integrity. 
  6. Technical obstacles need to be flattened to improve data quality and interoperability. These include: (a) adopt common definitions, nomenclature and minimum data sets that are inclusive of workforce cadres and consider local definitions; (b) establish mechanisms to resolve emerging taxonomy problems; (c) increase frequency of data reporting to quarterly; (d) improve validity and reliability of data; and (e) coordinate action with new processes such as civil registration and vital statistics systems. 
  7. Use of incentives to accelerate action by countries eager to build HRH data systems could prove beneficial and serve as implementation models for other settings. 
  8. Future WHA Resolutions and donor-driven health initiatives should contain specific language and resource appropriations for health workforce and support related HRH data, systems and impact measurement. 

Two initiatives that address health workforce data followed the inclusion period that defined our review and are noteworthy. The Measurement and Accountability for Results in Health (MA4H) Summit convened in Washington, DC, in June 2015, organized by the World Bank, USAID and the WHO focused sharply on health worker data and impact measurement. The MA4H Summit proposed an ambitious five-point call to action for measurement and accountability for health in the post-2015 era health in LMICs (World Bank, USAID and WHO 2015) that aligns with our recommendations and aims to accelerate health workforce data systems (Box 1). 

In July 2015, the landmark report on community health workers (CHWs), Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations, was published (Dahn et al. 2015). Supported by a consortium of funders, the MDG Health Alliance, Clinton Foundation, Partners in Health, the World Bank Group and African Leaders Malaria Alliance, along with the governments of Ethiopia and Liberia, this report is remarkable for the recommendations it lays out for investment in CHWs and a model of financing. Here too, health workforce data on CHWs are essential to assess stock, capacity and impact measurement of this vital and typically under-recognized cadre. 

 Box 1: Measurement and accountability for results in  health (MA4H): Five-point Plan 

  1. Increase the level and efficiency of investments by governments and development partners to strengthen the country health information system in line with international standards and commitments. 
  2. Strengthen country institutional capacity to collect, compile, share, disaggregate, analyze, disseminate and use data at all levels of the health systems. 
  3. Ensure that countries have well-functioning sources for generating population health data, including civil registration and vital statistics systems, censuses and health surveys tailored to country needs, in line with international standards. 
  4. Maximize the effective use of the data revolution, based on open standards, to improve health facility and community information systems including disease and risk surveillance and financial and health workforce accounts, empowering decision-makers at all levels with real-time access to information. 
  5. Promote country and global governance with citizen’s and community’s participation for accountability through monitoring and regular, inclusive transparent reviews of progress and performance at the facility, sub-national, national, regional and global levels, linked to health-related SDGs. 

 Source: World Bank, USAID and WHO 2015.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Over the past 15 years, the collective efforts of stakeholders in global health have moved health workforce up front and centre in the discussions on population health. In the coming months, we will witness two landmark events as UN member states act on the post- 2015 SDGs and the Global Strategy on HRH. The SDGs intensify the urgent need for global governance and national accountability mechanisms on data and measurement. The Global Strategy on HRH promises to coalesce the necessary consensus among global leaders, national governments and stakeholder to actualize HRH data systems. Going forward, stakeholders must stay mindful that implementation of HRH data systems is an ongoing and iterative process that requires vigilance and nimble structures to support improvements over time. The September 2015 United Nations General Assembly and the May 2016 WHA are two key opportunities for representatives of member states and stakeholders to recognize health workforce measurement as the key priority needed to improve population health. If we measure it, we can improve it.

About the Author

Marilyn A. DeLuca, PhD, RN, Principal, Global Health – Health Systems-Philanthropy, Research Assistant Professor, School of Medicine, Adjunct Associate Professor, School of Nursing, New York University

Sofia Castro Lopes, MS, RN, Research Associate, Instituto de Cooperacion Social IntegrareBarcelona, Spain

Correspondence may be directed to: Marilyn A. DeLuca
Email: marilyn.deluca@gmail.com 

Acknowledgment

The authors gratefully appreciate the comments provided by colleagues, especially to James Campbell, Executive Director GHWA and Director, WHO HRH, for his vision and leadership. 

Sections of this manuscript are reported in an unpublished background paper for Technical Working Group 3 (DeLuca, Campbell and Lopes 2015) for the Global Strategy on Human Resources for Health (TWG3 2015) and included in the Synthesis paper for the Global Strategy on Human Resources for Health (GHWA 2015). This manuscript is the first publication of the complete and updated paper  

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