Background
Methods
Search for existing frameworks
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Comprehensive frameworks aimed at supporting holistic decision-making around HRH policy, markets, and systems.
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Oriented towards improving health systems functioning and population health.
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Specific to the health sector.
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Includes a visual model (graphic conceptual framework).
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Narrowly focused frameworks targeting specific policy concerns (e.g. rural retention, balancing skill-mix of cadres, or external migration).
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Stepwise tools, guidelines, workforce projection equations, or similar, targeting specific components of HRH planning or policies.
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Frameworks focusing on a specific region or country that cannot be easily translated to other contexts.
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Close adaptations of frameworks already included in our analysis (to minimize overlap).
Review and synthesis
Interactive visualizer
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An online software application, centered around a visual graphic of the logic model, built using scalable vector graphics (SVG) common to many web pages.
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Visualization of the logic model components (as “text boxes”) with nested subcomponents (“boxes within boxes”), with the ability to expand and collapse components.
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Visualization of relationships and interactions between components and subcomponents across different levels (i.e., upstream vs. downstream) using arrows.
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Ability to isolate impact pathways and relationships within the model, by focusing in on specific desired outcomes, interventions, or components and subcomponents.
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Ability to overlay information (e.g., research publications, indicators) onto components and subcomponents, so that users can click to reveal embedded references to empirical literature.
Results
Search results
Name | Author | Year | Summary/objectives | Outcomes | Relation to the final logic model |
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HRH action framework [8] | World Health Organization (WHO) and Management Sciences for Health (MSH) | 2008 | Tool to guide policymakers and health managers to diagnose challenges with the health workforce (e.g., issues with shortages, distribution, competency, retention, and motivation) and determine solutions and implementation strategies to address underlying barriers, with the ultimate goal of improving workforce effectiveness and sustainability | Improved equity, effectiveness, efficiency, and accessibility of health services, leading to better health outcomes | “Action Fields” adapted to elements of the “Health system factors” |
HRH in Fragile States [12] | Fujita et al | 2013 | Adaptation of the HRH Action Framework tailored for post-conflict, fragile health systems. Builds on HRH Action Framework by including more specific HRH policy and intervention areas to affect HRH outcomes in fragile settings | Human resource systems that are responsive to health needs | Foundational components of health system adapted to “Health system factors” HRH policy areas adapted to “Health workforce processes” |
Developing the health workforce for universal health coverage [26] | Cometto et al | 2020 | Framework on individual, organizational, and systemic capacity-building for successful stewardship of HRH—building on HRH Action and systemic capacity-building frameworks [8, 64]. Shows health workforce policy levers at the individual and organizational levels and systems and contextual factors that are required for and enable effective HRH governance. Synthesizes effective policies for health workforce development within each HRH Action Field | Optimizing health workforce management to achieve UHC | Systemic capacity-building framework adapted to “HRH system governance” |
Health worker productivity and performance [10] | Dieleman et al Also adapted by Global Health Workforce Alliance [25] | 2006 2014 | Logic model to depict strategies for improving the performance and productivity of the health workforce. Shows the interrelated mechanisms and contextual determinants that lead to health workforce outcomes, effects, and impacts | Improved performance and productivity (responsiveness, availability, and competency), leading to health improvements | Macro-level context adapted to “Contextual factors” Inputs adapted to “Health system factors” Processes adapted to “Health workforce processes” Outputs and Outcomes adapted to “Health workforce outcomes” Effects adapted to “Health system outcomes” |
Systematic Approach to Health Workforce Management [28] | Dubois and Singh | 2009 | Framework for HR optimization, using a systems perspective to enhance the organizational unit. Management strategies should be aligned with one another and situated within the organizational environment and wider political, social, legal context—with individuals responding to organizational context, and organizations responding to policy environments | Organizational, staff, and patient outcomes | Institutional context adapted to “Contextual factors” Organizational context adapted to “Health system factors” Human resource management strategies adapted to “Health workforce processes” |
Comprehensive health labor market framework for universal health coverage [26] | Sousa et al | 2013 | Stresses that policymakers should take a more comprehensive market-based approach, beyond simply training more health workers. Shows how policy areas can affect and interact with health labor market dynamics and the education sector—which in turn shape the distribution, pay, quality, performance, etc., of the health workforce | Workforce able to deliver quality health services to achieve UHC | Education sector, labor market dynamics, and societal drivers adapted to “Contextual factors” Policy areas adapted to “Health workforce processes” |
Framework with health workers at the core of the health system [11] | Anand and Bärnighausen | 2011 | Framework that depicts health workers as the central element of a functioning health system, arguing that all functions of the health system depends on health workers, their activities, and the system elements that influence them | Appropriate size, composition, and distribution of health workforce providing access to treatment to improve population health and patient satisfaction | Health/HRH system inputs and mechanisms adapted to “Health workforce processes” Health workforce outcomes and activities adapted to “Health workforce outcomes” |
Stages of Health Workforce Development [13] | WHO | 2006 | "Working Lifespan" approach for analyzing and responding to dynamics of the health workforce. Strategies and policy interventions relate to stages of health workforce entry, participation, and exit | Availability, competence, responsiveness, and productivity of the health workforce | Entry, Workforce, and Exit cycle and policy options adapted to “Health workforce processes” Workforce performance outcomes adapted to “Health workforce outcomes” |
Imbalances in the health workforce [27] | Zurn et al | 2004 | Depicts the factors that affect imbalances in the health workforce (supply and demand of health labor, the health care system, policies, resources, and "global" factors). Develops policy tools to address these factors based on a typology of imbalances: profession/specialty imbalances, geographical imbalances, institutional and services imbalances, and gender imbalances | Correct health workforce imbalances | Wider context adapted to “Contextual factors” Policies adapted to “HRH policy formulation and implementation” Health Care System and Resources adapted to “Health system factors” |
Framework for analysis of health workers labor market dynamics [14] | McPake et al | 2013 | Uses health labor market analysis (predominantly supply and demand analysis) to unpack factors behind HRH constraints, to more effectively design policies that can affect health labor markets and subsequent employment conditions. Focused on accelerating progress towards UHC | Improved quality of care and productivity of health workforce, increasing overall health systems performance | HRH regulation and governance adapted to “Health system factors” HRH management, motivation, incentives, and training, education, migration, retirement, deaths adapted to “Health workforce processes” Supply for HRH and HRH employment adapted to “Health workforce outcomes” HRH performance adapted to “Health system outcomes” |
Logic model
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Social, legal, environmental, and epidemiological factors: the legal system (regulation and law enforcement); the basic and professional educational system; epidemiological and environmental factors that affect population distribution and health needs; levels of equity and/or marginalization of different groups (e.g., socioeconomic, gender, race, ethnicity, education, etc.), and levels of corruption [33].
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Economic factors: strength of the economy, nature of health markets—including levels of care, financing, and service provision—and larger labor market forces that affect health workforce distribution, public and private decision-making, and HRH outcomes.
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Political factors: decentralization of power and decision-making; the type and capacity of political regime in power and its level of “political entrenchment”; and the influence governmental and non-governmental stakeholders have on policy adoption and implementation [34].
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HRH system governance: leadership, processes, and capacities for governing HRH systems. This includes: individual, organizational, and systemic capacity for management and decision-making; collaboration and coordination within and across sectors and ministries for multisectoral action; transparency and accountability to government and communities; and corruption within the HRH and broader health systems [35‐41]. Electronic human resource management systems (e.g., managing postings, performance, attendance) along with systemic capabilities to use data for workforce planning, regulation, and decision-making are important aspects of governance [36, 37]. Governance is affected by a wider national and international context, and influences HRH policy formulation and implementation.
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HRH policy formulation and implementation: areas of strategy and planning around health workforce objectives; financing allocations and mechanisms to implement HRH interventions and policies; regulatory policy and legislation around medical practice and health workers (e.g., scope of practice for each cadre, and/or expansion of functions); contract compliance of entities engaged to provide health services; and day-to-day operating procedures. Policymaking and implementation are affected by factors of HRH governance.
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Production of health workers: policies or factors influencing pre-service training of health workers which are generally used to affect the size, composition, competencies, and distribution of HRH. These could include admissions policies or regulation of the quality and distribution of training institutions—whether public or private [43].
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Entry into the health workforce: recruitment strategies and equitable distribution (deployment, reallocation) of the workforce per health system needs and across public and private sectors. Foreign-trained workers may also enter into the health workforce in some countries, dependent on regulations. The stock of health workers trained and the supply of workers currently functioning in a labor market may be different (due to exit from the health labor market, or inability to find work in the health labor market).
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Maintenance and performance: strategies used to retain health workers (particularly in remote underserved area) and manage their performance. These include clinical quality interventions (e.g., job aids or tools to support quality and work flow), performance management systems to measure and develop health worker performance [44, 45], in-service training to maintain and strengthen competencies, supportive supervision, and regulation of practice to ensure quality of care. In addition, it includes financial and non-financial incentives to promote health worker motivation, performance, and retention in remote underserved areas [46‐51].
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Enabling environment: HRH outcomes will be affected by the environment within which the workforce operates. This includes healthcare facilities and infrastructure, availability of supplies and equipment, other health systems building blocks, and living conditions (i.e., road infrastructure, housing, and quality of local schools) [43, 48, 49, 52].
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Health worker exit: exit from the workforce can be a natural progression (e.g., retirement), attrition due to pursuit of alternative careers, migration to locations with better living and working conditions, or a lack of sufficient incentives or motivation to remain in the health workforce.
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Availability: availability of health workers to ensure geographic coverage according to population health requires having appropriate numbers of health workers, equitable distribution across urban and rural areas, and skill-mix across the cadres of healthcare workers.
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Will do: worker and team satisfaction, engagement, and motivation are critical for the competencies of health workers to translate into practice. “Engagement” refers to vigor and energy devoted to one’s work; involvement, dedication to, and enthusiasm in work; and absorption and identification with one’s work [53, 54]. Motivation and engagement of health workers support a drive towards quality and improving health outcomes, which supports responsiveness, efficiency, and equity of care [1, 55]. This is known as the “know–do” gap between provider skills and their application of these skills when delivering services [56]. These factors are also important for influencing retention of health workers.
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Can do: required competencies (knowledge, skills, and attitudes) that are critical for health workers to provide care with high clinical and non-clinical quality, based on designated roles and responsibilities.
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Quality of service delivery in accordance with predefined standards and protocols, including clinical quality and non-clinical aspects such as safety and equity [2].
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Coverage of health workers across both urban and rural areas according to population health needs.
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Efficiency in utilizing financial and non-financial inputs, including appropriate skill-mix based on available human resources.
Discussion
Current uses
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Evidence-to-policy process: we see the visualizer being useful in supporting the evidence-to-policy translation process because it provides a visually engaging and comprehensible format for exploring evidence behind key policy questions. Several barriers have been identified in the translation of research for policymaking, including succinct communication of complex methods and ideas, and insufficient time and capabilities for unpacking academic papers and understanding their implications on local context [58‐60]. This tool can help address this gap and make the evidence behind policy options more comprehensible for policymakers.
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Education and training: by synthesizing current HRH frameworks and their linkages, this tool can illustrate higher-level policy pathways and relationships between HRH system components. It will allow learners to explore the pathways by which upstream factors and external forces affect the HRH lifecycle, and by which HRH processes contribute to health system outcomes.
Future uses
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Synthesizing and building health workforce evidence: the visualizer can be used to build consensus around existing and missing evidence on strengthening the health workforce, thereby serving as a dynamic platform that bridges the gap between evidence, policy, and practice. Researchers can use this tool to receive feedback from policymakers for directing future research questions, to ensure they can be of value to policymakers.
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Developing mathematical models: increasingly in global health, stakeholders want to quantify the potential impact of alternative policy options, or the resources required to achieve targets. Mathematical modeling has an important contribution to make in this regard, but until now, most HRH modeling has involved associative models that do not describe the causal pathways between factors [61‐63]. Future modeling could involve causal models, in which mathematical models are grounded in an a priori understanding of how upstream determinants interact to affect a workforce and achieve health outcomes. This tool can serve as a base for developing such mathematical models.