Connecting Policy and Practice using Needs-Based HRH and Health Care Service Planning: Partnership between Zambia and Canada.

Author(s) Fastone Goma1, Gail Tomblin Murphy2, Adrian MacKenzie3, Gogi Greeley 4, Selestine Nzala 5, Miriam Libetwa6, Fred Montpetit7, Kenneth Rockwood8
Affiliation(s) 1School of Medicine, University of Zambia, Lusaka, Zambia, 2WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 3WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 4Department of Health and Social Services, Government of Nunavut, Iqaluit, Canada, 5School of Medicine, University of Zambia, Lusaka, Zambia, 6HRH Directorate, Zambia Ministry of Health, Lusaka, Zambia, 7Department of Health and Social Services, Government of Nunavut, Iqaluit, Canada, 8School of Medicine, Dalhousie University, Halifax, Canada
Country - ies of focus Canada,Zambia
Relevant to the conference tracks Advocacy and Communication
Summary In the midst of a global human resources for health (HRH) crisis, researchers and decision-makers are seeking new and innovative evidence-based strategies for HRH planning. For several years, Canadian and Zambian researchers and policy and decision-makers have been working to adapt a needs-based approach to develop service-based strategies and tools for HRH planning. This approach is based explicitly upon the needs of people, considers the multiple contextual and process factors in the different country contexts, and aims to improve patient, provider and system outcomes.
Background Historically, HRH planning in Canada and Zambia, as in most countries, has been based on supply, use and/or health care expenditures. None of these approaches account for changes in population health needs, provider productivity, or models of care delivery. Since most of Zambia and parts of Canada face critical HRH shortages, it is essential to make the most efficient possible use of these scarce resources in the short term, and to adopt more responsive HRH planning methods in the long term. Service-based HRH planning compares the number and type of services required by populations, given their needs, with the capacity of existing HRH to perform those services. This allows policy makers to collaborate with researchers, educators and providers to identify and compare strategies to address health care system gaps at the level of specific services rather than for particular professions. The unit of analysis used in this framework is the particular health care service that is to be performed by a health care provider to address a certain health care need within the target population. This contrasts with most HRH planning approaches where the health care provider is the unit of analysis.
Objectives The purpose of this paper is to describe the adaptation and application of an analytical framework for service-based HRH planning to different contexts in rural areas of Canada and Zambia. Specific objectives are to: (a) Provide an overview of the analytical framework for service or competency-based HRH planning; (b) Describe the processes used to engage partners in adapting the framework to inform planning in the northern Canadian territory of Nunavut as well as the rural Zambian districts of Chibombo and Gwembe; and (c) Share the lessons learned through collaboration between the researchers and policy and decision-makers across sectors in each application, at the district, provincial/territorial and national levels.
Methodology The framework calls for two quantities to be estimated and compared: how often a particular service is required by the target population (requirements), and how often that service can be performed by the available health workforce (supply). Estimating the first requires the identification of the leading health conditions which drive the need for health care (according to whatever criteria are deemed appropriate by planners in their particular context, such as rates of mortality and/or morbidity), knowledge of the size of the population and the incidence or prevalence of each leading condition within it, the range of health care services required to address each condition, and the frequency with which each service is required by persons with those conditions. Estimating the latter requires data on the size of the available health care workforce as well as their level of participation in it, their levels of activity (e.g. hours worked) and productivity (e.g. cases treated per day), and the prevalence of the competency to perform each service across the existing workforce.The study in Nunavut was funded by Health Canada. The Zambia Study was funded as part of the African Health Systems Initiative. In Zambia, the study was conducted in two rural districts - Gwembe and Chibombo – and considered the needs of their entire populations. In Canada, the study was conducted in the northern territory of Nunavut and was specific to the needs of older adults. In both Zambia and Canada, the research and stakeholder engagement processes were guided by steering committees of local clinicians, educators and policy-makers. Leading health conditions were identified using a combination of administrative data consultations with local stakeholders. Data on population size and the incidence or prevalence of each condition were obtained from administrative sources. The number and type of health care services required to address these conditions were compiled based on published guidelines and then validated by local clinicians. The size and characteristics of the existing health workforces were estimated using a combination of administrative records and a questionnaire administered to health workers in each jurisdiction.
Results The primary health conditions identified in the two Zambian districts were HIV/AIDS and malaria. Although the competencies of the districts’ existing health workforces mostly aligned with these conditions, some substantial gaps were found. The largest gaps identified in both districts were performing laboratory testing and interpreting results, performing diagnostic imaging and interpreting results, taking and interpreting a medical history, performing a physical exam, identifying and diagnosing the illness in question, and assessing eligibility for antiretroviral treatment. In both districts, these services are required very often yet few HWs report feeling competent to perform them – a combination of high need and low supply.Leading conditions among older adults in Nunavut were arthritis, cancer, chronic obstructive pulmonary disease (COPD), diabetes, and hypertension. As in Zambia, while the competencies of Nunavut’s existing health workforce were largely aligned with the health care service needs of its older adults, there were some significant gaps. The largest of these related to ongoing client assessments (mental health, safety, and fall risk), pharmacy services (dispensing, monitoring effectiveness, and addressing polypharmacy issues), and client and family education (related to health promotion and goal setting). Similar to Zambia, these gaps were present because, although required frequently by older adults in Nunavut, relatively few members of the territory’s health workforce have the knowledge, skills and judgement to provide these services.These findings were discussed in deliberative forums in Zambia and Canada with participants representing clinicians, government, educational institutions, regulatory bodies, and health care organizations to ensure their validity and to discuss potential strategies to address the identified gaps. Some suggested solutions for Zambia included targeted professional development in the short term, and, in the long term, increased collaboration between health and education to better align the latter with population health needs, and increased collaboration across sectors to improve living and working conditions for the workforces in these districts. Some strategies suggested for Nunavut included increased dialogue to improve coordination between the home and acute care sectors and between health and education, and expanded use of electronic health records to reduce polypharmacy issues.
Conclusion Although each of the jurisdictions studied possess active, productive and competent health workforces, each also has significant gaps in the services it can provide to meet the health care needs of their populations. The rural and remote locations of the communities in these jurisdictions makes recruitment and retention of highly trained professionals, not limited to HRH, an ongoing challenge. In the short-term, on-site training of existing health workers may be the best approach to address specific competency shortages. In the long term, along with investments in improved infrastructure, continued use of the service-based approach will enhance policy-makers’ ability to align the training, management and deployment of health workforces to meet the needs of its people. This approach provides the flexibility needed to change the composition of health care workforces to align with the changing health needs of the people they serve. The application of the service-based framework in this setting and the relevance of findings to dialogue with policy makers and clinical stakeholders demonstrate its potential utility for other jurisdictions and health care settings in Zambia, Canada, and internationally.The studies in both countries were limited by low numbers of participating health workers, and by the use of self-reported data to measure important concepts such as competence. However, the study’s findings were validated by local steering committees as being consistent with their experiences.In addition to the applications of the service-based approach to HRH, there were a number of mutual learnings from the collaborations between and among researchers and researcher users in these studies. These lessons learned included: 1) the importance of understanding the unique health governance, cultural, economic, historical and political contexts in each country and/or regional setting; 2) the importance of engagement and time to build effective, respectful and trusting partnerships with all stakeholders, across multiple sectors, including researchers and research users; and 3) the importance of capacity building to creating viable processes and strategies for human resources for health and health system sustainability. Most importantly, these connections are key examples of how multi-sectoral partnerships support shared accountability for integrated solutions for HRH planning to advance local and global health.

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