Information systems on human resources for health: a global review

In 2000, the global community made a historic commitment to combat poverty and its main causes and manifestations by agreeing to eight Millennium Development Goals (MDGs), four of which directly target improved population health outcomes through strengthening of health systems and human resources for health (HRH) [1]. The recognition that attainment of the health-related MDGs is directly related to an adequate supply and distribution of trained health workers has resulted in advocacy for increased action and investment in HRH [2‐6], especially among 57 resource-limited countries identified by the World Health Organization (WHO) as experiencing acute workforce shortages [2]. This awareness has been accompanied by international calls to strengthen “systems for recording and updating health worker numbers [that] often do not exist, which presents a major obstacle to developing evidence-based policies on human resources development,” such as articulated in the WHO’s World Health Report 2006[2]. Table 1 identifies eight recent global and regional calls to action for strengthening the information and evidence base to support HRH policy and planning [7‐14].

While there is no single data source or indicator that can capture the various dynamics of HRH stocks and flows, a number of different data sources exist in most countries that can potentially be used to glean information about the health workforce, including population censuses, labor force and employment surveys, health facility assessments, and administrative databases for human resources management (e.g. health professional licensing and payroll databases) [15, 16]. However, many of these sources were not designed for the specific purpose of supporting HRH policy and planning. The global evidence-base regarding the impact of HRH on health systems and health outcomes remains largely fragmented and incomplete, partly due to a lack of institutional capacity in many countries to collect and use these data to support HRH decisions, and partly due to a lack of awareness among the international community [5, 15]. Until recently, tools for measuring and monitoring HRH offered few norms and standards for comparison, and available data are still largely inconsistent within and between countries, which limits opportunities for understanding effective workforce strategies and interventions [15‐19].

Increasingly, systems for collecting and disseminating information on a country’s health workforce – referred to as human resources information systems (HRIS) – are becoming an integral component to national HRH performance assessment and systems strengthening frameworks [15, 20‐24]. Functional HRIS models involve standardized processes for data capture, management, and use so as to provide accurate, timely, and comprehensive profiles of workforce size, composition, and deployment [15, 25‐27]. When comprehensively designed and implemented, HRIS empower decision makers to anticipate a variety of HRH issues, such as an insufficient supply of younger workers entering the health system who can offset employee departures due to retirement, death, or out-migration. They facilitate meaningful integration of workforce data across multiple information points, for example, by ensuring health ministries (and other employers) that health professionals on staffing or payroll records are appropriately credentialed and qualified to practice (based on registries of professional regulatory bodies). They are used to collate data on workers in government-operated health facilities, private (for-profit or non-profit) and parastatal facilities, as well as those working outside of facility-based service delivery. The systems collect data on all human resources: physicians, nurses, and midwives, plus other categories of allied health professionals and technicians, as well as the management and support personnel necessary for sound health system functioning. In addition, linking HRIS data with broader health information – such as disease burden, health services utilization, and patient outcomes – can be a powerful tool in prioritizing resource allocation for health worker training and deployment in order to meet health system goals.

The need for quality information is pressing for ensuring greater efficiencies in health systems, as well as for ensuring improved accountability and good governance through performance monitoring of national and donor-supported HRH initiatives [18, 23, 27]. Because countries with varying stages of social and economic development are at different stages in HRIS development and use, there is a heightened need for global consensus regarding standardized approaches to assessing HRIS performance.

In 2010, with five years remaining to the MDGs deadline, stakeholders representing WHO, Health Metrics Network (HMN), Global Health Workforce Alliance, and other national and international agencies convened the Health Workforce Information Reference Group (HIRG), a technical working group focused on prioritizing national HRH data collection and use, including building capacity in HRIS strengthening and assessment [28]. While the HIRG has noted that tools to support HRIS development are growing [15, 29‐31], there was also collective recognition that scant baseline information existed regarding the scope and adequacy of existing HRIS implementation worldwide.

Since there has not been an extensive study of HRIS implementation on a global scale thus far, we conducted a comprehensive literature review in order to draw a baseline portrait. The objectives of the review were to: (i) review and systematically assess national practices in HRIS implementation worldwide; (ii) identify the main areas of weakness in HRIS implementation, with attention to countries facing acute health workforce shortages; and (iii) draw upon documented best practices to offer recommendations to ministries of health and global health policy makers on how to improve the science and application of human resources information and monitoring systems.

Our study entailed a structured review process of scientific publications and grey literature. Given the innovative nature of our research, we adapted the Cochrane methodology of conducting systematic reviews on the effects of health care interventions [32]. Following searches of several global and regional bibliographic databases, we employed a more flexible search strategy to better capture unpublished and grey literature. We also developed a unique quantitative data abstraction tool appropriate to the topic.

Despite growing demand at the national and international levels for improved HRH data and analysis to support evidence-based policy, planning, and programming, our findings highlight the critical gap regarding HRIS processes capable of generating needed information. Our review demonstrates the dearth of publicly available information on HRIS implementation and the limited ability to identify criterion for standard practices regarding nationally generated data that are essential for sound HRH decision-making. While there is scant HRIS documentation in the grey literature, HRIS scientific literature published in peer–reviewed journals are even rarer.

Among the 63 documented national HRIS experiences, the literature reviewed could only confirm that while crisis and non-crisis countries tend to generate basic HRH supply and deployment data, few seem to be explicitly using this information for making workforce decisions. In particular, countries with acutely scarce resources, those most in need of efficient HRH utilization, frequently lacked systematic capability to collect or retrieve information on different dimensions of workforce dynamics, such as qualifications, distribution, and retention. Few HRIS were documented as collecting workforce demographic data (e.g. age and sex), essential for effective HRH planning. The small number of countries reported to be collecting data on workforce attrition further underscores the limited global capacity to monitor implementation of the WHO’s recently adopted Global Code of Practice on the International Recruitment of Health Personnel [8]. As noted in Table 1, this new Code also advocates for establishing or strengthening national HRIS especially with regard to health personnel migration.

Complicating any understanding of HRIS performance is the lack of documented ability of most information systems to effectively capture data on different types of health workers from more than one type of employer and link them across service areas. When juxtaposed to the major global and regional commitments to supporting HRH development in resource-limited countries, this imbalance underscores the importance for addressing the paucity of available HRH information and the need for more focus on HRIS strengthening and reporting. The fragmentation of data generation, management, and use found in this review indicates that, of the currently documented data systems, few are capable of drawing a strategic and dynamic picture of the health workforce and its ability to meet population needs.

As previously noted, this review only assessed information that had been documented in selected languages in peer-reviewed journals or grey literature. Some areas of the world may not have been well captured, notably much of the Eastern Mediterranean and European regions. So as to ensure uniformity of data abstraction, articles with insufficient information regarding HRIS implementation were excluded. Our searches did not include specific concepts that might have better identified documents about national HMIS models in which HRH data were systematically embedded. As a result, these findings may have overlooked promising HRIS models that have yet to be publicly described. Also, some HRIS performance indicators originally included in our abstraction tool, notably those regarding system sustainability and ownership, were excluded from the final results due to lack of meaningfully extracted information; this dimension may not be relevant to all countries across levels of development. Since, to the best of our knowledge, standardized abstraction tools specific for HRIS assessment did not previously exist, this review required the creation of an instrument to facilitate data retrieval, one that was not pre-tested or adapted from validated instruments. More formal validity testing of our tool is needed to strengthen its scientific application.

Despite these limitations, we believe this study provides much needed information on the current global status of HRIS performance, one which can serve as both a catalyst for further research generation and dissemination on this topic, as well as a baseline for future investigations. For one, our searches of bibliographic databases uncovered no articles dated prior to the year 2000, highlighting the innovative nature of this topic.

Based on this literature review, our findings indicate the need for more attention to strengthening and reporting the following HRIS features:

· Capability to collect and collate data on HRH across the working lifespan and from multiple sources including payroll records, professional regulatory bodies (where applicable), pre-service training institutions, and population-based census and survey sources;

· Capability to collect and collate deployment data across multiple sectors (e.g. public, private-for-profit, private non-profit, faith-based);

· Capability to link HRH data to broader health information, such as data on population needs, service utilization, and patient outcomes;

· Implementation of methods for data cleaning, validation, and management that allow regular updates (e.g. at least once per year for administrative data); and

· Use of HRH data for policy and practice including strategies for the training, deployment, and retention of health workers.

The scarce documentation of HRIS reflects the current deficiencies in the availability of comprehensive HRH information for use by governments and other stakeholders. Despite increased focus on the inadequate supply and distribution of health workers in low-resource countries − and increasingly in developed countries − support for the development and evaluation of systems to generate the critical HRH data remains limited. Further research on HRIS implementation processes is needed to guide efficient and effective approaches to inform and evaluate health workforce policies and investments at the national and global levels.

We declare that we have no conflicts of interest and that there was no institutional or organizational funding awarded for this study.

PR, JC, and AZ conceptualized the study and designed the protocol. PR, AZ, AV, and NG conducted the literature search. SV and NS conducted data entry and analysis. PR, AZ, AV, and JC prepared the first draft of the manuscript. All authors participated in the literature review, contributed to the interpretation of the results, and read and approved the final version.