Health Workforce Projections: Tools for health workforce strategic 

plan development

Nonglak Pagaiya, PhDSirindhorn College of Public Health, Khon Kaen

GHSA Meeting: 4‐year Workplan Development & Strengthening Workforce Development  7‐8 February 2017, Bangkok, Thailand

1

Why HRH is important?

Human Resources for Health (HRH), Health Workforce• skilled personal delivery• “HRH ” use other resources• “HRH ” critical factor for the health system• “HRH ” consume 60 – 80 % of the operational Budget

2

Presentation Topics

• Relationship of HRH and health service system• Principle of HRH Projection

– Information for HRH projection– Population ratio– Health Needs– Health Demand– Service Target

• HRH projection and HRH Planning

3

4

1. Relationship of HRH and health service system

Health NeedsDemographicDisease Burden

Epidemics

ContextGlobalization

Socio‐economic

NumberShortage

DistributionRural / UrbanPublic / PrivateGP / Specialist

Skill MixHealth team imbalance

MotivatedRemuneration

Non‐financial incentiveWorkplace safetyPatient relationship

Driving Forces Workforce Challenges

Accessible

Qualified

Cost‐effective

Responsive to needs

Services objectives

Health SystemPublic sector reform

TechnologyConsumer preference

Health NeedsDemographicDisease Burden

Epidemics

ContextGlobalization

Socio‐economic

Health SystemPublic sector reform

TechnologyConsumer preference

Health NeedsDemographicDisease Burden

Epidemics

ContextGlobalization

Socio‐economic

WHO 20064

5

1. Demographical transition Increase of elderly, decrease of childrenThailand: from 10.9 % in 2005 and to 15% in 2015 and to 23% in 2025

2. Disease burden Communicable diseases (CD)Increase of chronic: DM, HT, Heart disease

3. Epidemiological transitionEmergence of new diseases: AVIAN Flu, SARS, H1N1,

ZiKaAccident, Emergency & Disaster

Dynamic of Health Needs

5

6

1.Health Care Reform UHC implementation have changed service delivery system/

financial system/ HRH

In Thailand: service utilization increased after UHC 2. Public sector reform Public sector reform– reduce government staff

Decentralization to local authorities 3. Technology changes Improve communication channel

Require appropriate skill- skill substitutions4. Consumer expectation high expectation for quality of care

Dynamic of Health system

6

7

1.Globalization International trade: increase foreign patients to use services

in Thailand, increase 13.04 – 15.87% annually

Asian Community, FTA– Free flow of HRH and patients among countries Medical Hub Policy

2. Macroeconomic policy

Expand of private hospital: Thailand, beds increased from 7.4 % in 1973 to 20.2% in 2005

Other Contexts

7

What aspects of HRH should be prepared?• Right Number

– Adequate type and number of HRH• Right Distribution

– Equity distribution of HRH in relation to: • Rural VS Urban, • Level of Care (primary, secondary, tertiary, supra‐tertiary), • Public VS private• Prevention and curative care

• Right Skill mix– Appropriate skills related to population health needs– Health team balance, skill mix

• Motivated HRH– Retention, motivated to work– High productivity

8

Context changes Health needs & demand

Health system

HRH requirements

HRH management‐employment‐incentives‐supportive system

Future HRH supply

Existing HRH

New graduates

Return to work

Move in

loss

CHANGE

Future HRH requirement Future HRH 

supplyIdentify gaps?

Future HRH requirement2. HRH Projection

1 2

3

Hornby 2007

Plan (Project) long,

Act short,

Update often

Plan (Project) long,

Act short,

Update often

Principle of HRP :Principle of HRP :

HRH requirement

projection methods

• Population ratio• Health Needs 

• Health Demand • Service Target

Information for HRH projection

• Projected Population• Economic situation and trend• Epidemiology information• Service utilization of both public and private sectors

12

Information for HRH projectionStaff norm• Standard of working hour in each country, i.e., in

Thailand-HRH work 230 days per year, and 6-8 hour per day

• Working hour per year is 1,680 hourProductivity• Outputs in relation to inputs, i.e., 360 pairs of shoes

produced by 12 workers– the average productivity of each worker is 30

• Physician can provide services at out patient department at about 7-12 minutes/ case

Productivity data sources

• Professional councils/ associations• Expert Opinion• Study• Mix of 3 approaches

14

How to use HRH productivity to convert into HRH requirement

Nursing productivity•Out patient service for nurse takes 0.25 hrWorkload calculation•Out patient utilization 30,000 visit/ year•Workload = 30,000 * 0.25 = 7,500 man hourNurse requirement•Compare workload to staff norm (240 day *7 hr) = 1,680 hour per year•Nurse requirement for OP services =7,500/1680= 4.5 Full Time Equivalent (FTE)

15

2.1 Population ratio method.

Demographic trend National Planning Board

International comparison Ratio in favored areas Recommended standard (bench mark) Past trends Expert opinions

AffordabilityDemand

Projectedfuture population

CurrentPopulation

Projected futureHRH

requirement

Required futureHRH/population

ratio

CurrentHRH/population

ratio

Population ratioProject HRH requirement base on proposed thresholds for workforce density, i.e., • 1 physician per 10,000 population, 1 nurse per 5,000 population•District A with 30,000 population, how many physicians and nurses required? •physician requirement= 30000/10000 = 3•Nurse requirement= 30000/5000 = 6

17

18

Population ratio

• Strengths– For stable health system and all people access to care– Simple and require less data – population growth and

standard population ratio• Weakness

– Individual cadre projection, lack of teamwork or skill mix projection

– Does not address other key factors– Limitations to solve distribution problems– Homogeneity of HRH productivity and population

health needs

Modified population to HRH ratio methods

Sirikanokwilai et al

Relationship between population/doctor ratioand GDP per capita (ppp.)

7,358

12,612

2,298

9,523

2,165

12,500

9,851

4,255

5,882

4,381

2,000

1,0161,034

5,888

6,786

1,320

1,750

220

3,140

983847

4,361

600

2,063

855700

928

321195

581438

320333

1,133

446545699

802585

391

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

0 5,000 10,000 15,000 20,000 25,000 30,000

GDP per capita (ppp) USD

Popu

latio

n/do

ctor

Thailand

Relation between GPP/capita andpopulation/doctor ratio 1995

5,000

10,000

15,000

20,000

25,000

Nonthaburi

Rajchaburi

PatumtaniSamutsakorn

SamutprakarnRayong

50,000 100,000 150,000 200,000 250,000 300,0000

GPP/capita (Bahts)

Srisakate

0

Population/doctor

Bangkok

2.2 Health needs methods2.2 Health needs methods

Expertopinions

Health needs(Epidemiological

information)

Kind, quality, frequency, numberof services needed to reach a standard of good health care.

• Affordability• Demand

Service targets

Productivitynorms

HRH/population

Total HRHrequired

Cadre mixes and time requiredby each cadre to perform

the services

Health Need Method

• Use epidemiological data, health problem and professional judgment to design service provision

• Use “staff norm and productivity” convert into HRH requirement, for example dental health services

23

Health problem services Target HRH

Adult 50%-out patients-prevention service

30% DentistDental nurse

Children 80%-out patients-prevention service

50% DentistDental nurse

Health Needs method

• Strength– Comprehensive health services and HRH requirement cover curative, promotion, protection and rehabilitation services

– Facilitate skill mix approach• Weakness

– Require accurate health information system– Need technical support in HRH projection– Trend to rely on professional judgment

24

2.3 Health or economic demands method2.3 Health or economic demands method

Currentutilization

rates

Demographic and

social trends

Productivitynorms

HRH/population Future utilizationrates

Future HRHrequired

Projection of future populationparameters

Current populationparameters age income occupation health insurance coverage

sex residence education

Statisticalcorrelation

Health Demand method• Use current and trend of service utilization in the

future• Use “staff norm and productivity” convert into

HRH requirement, for example drug dispensing services

26

Service utilization HRH Productivit

y (hr) workload

100,000 Pharmacist 0.08 hr 8,000 hr

Pharmacy Technician 0.1 hr 10,000 hr

Health Demand

• Strength– For stable health system and all people access to care– For private‐dominated health system

• Weakness– Curative‐oriented approach– requires consideration of multiple variables– Require accurate health information system– Need technical support in HRH projection– Limit to use in country with inequity access to care/ capacity to pay

27

Expert opinion Planners

Healthauthority

Past trends Health needs Economic demands Development of the delivery system

Productivitynorms

Staffingstandards

Service targets Health services facilities development targets

Total HRH requiredHRH/population

2.4 Service targets method

Comparison of HRH requirementprojection methods

Methods Advantages Disadvantages Appropriate condition

Populationratio

Easy Macro Limited planning

Healthneeds

Logical Very difficult Strong planningDominant publicHigh public awa.

Servicetargets

Not verydifficult

Sometimesunrealistic

Dominant publicActive government

Economicdemand

LogicalEconomically

feasible

ComplexStatus quo

Dominant privatePassive government

3. HRH Projection lead to HRH Planning

30

Future HRH requirement Future HRH 

supplyIdentify gaps?

Measures to redress gaps

Policy Levers to shape HWF labor market

Source: Sousa et al 2013 31