Framework and Tools

The Conceptual Framework

Our methodology is based on an established conceptual framework for needs-based health systems and HHR planning (see figure below). This framework captures the dynamic interplay among the determinants of provider supply and requirements that in previous models have been treated, often implicitly, as independent and, in many cases, constant.

The conceptual framework has been customized for different country settings and enabled these countries to build capacity for research, research use, strategic planning, evaluation and knowledge translation for the development of improvement of human resources for health.

In 2006, the conceptual framework was adopted by Canada’s Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources (ACHDHR).

conceptual framework

The outer circle (oval) of conceptual framework indicates that HHR planning occurs within the context of many social, political, geographical, technological, and economic factors. Fundamentally, however, HHR planning starts with the population health needs of the jurisdiction for which one is planning (e.g., country, province or region). Across all sectors of care (system design) it works with the current practice pool (supply) of providers. That supply is maintained by the production of new providers, and the flow of services from that supply is influenced by the level of financial resources applied and the management and organization (e.g., models) of service delivery. The flow of services from that supply of human resources will also be influenced by the deployment (e.g., in direct clinical care versus administration and research) and utilization (e.g., full- versus part-time) of these resources. These human resources, when supported by non-human resources (e.g., facilities and technology), yield patient, provider and system outcomes that are optimized when there is an efficient mix of human and non-human resources in the jurisdiction.

Relevant citations:

Tomblin Murphy G, MacKenzie A, Alder R, Birch S, Kephart G, O’Brien-Pallas L. (2009). An applied simulation model for estimating the supply of and requirements for registered nurses based on population health needs. Policy, Politics, & Nursing Practice10(4), 240-251.

Birch S, Kephart G, Tomblin Murphy G, O’Brien-Pallas L, Alder RMacKenzie A. (2007). Health human resources planning and the production of health: A needs-based analytical framework. Canadian Public Policy, January; 33(S1):1-16.

The Analytical Framework

Using the theoretical and conceptual approaches in the conceptual framework, researchers from the Collaborating Centre developed an analytical framework (Birch et al., 2007) based on the health needs of the population that considers the multi-factorial nature of HHR. The framework is based upon four key data elements: the demographics of the population, epidemiologic parameters such as health risks and population morbidity, the care required to meet the health needs of the population and the productivity of providers. Using this information, the analytical framework provides equations to measure two independent elements: provider supply and provider requirements.

Provider requirements—that is, the number of a given kind of health care provider required to deliver a given set of services to a particular population based on their levels of need—are estimated using demographic, epidemiologic, level of service and productivity data.

Provider supply is an estimate of the number of providers that are or will be available to deliver health based on the size of the current stock of these providers, flows in and out of supply, and the levels of participation (e.g. active in providing patient care vs. those who are working solely in administration, education, research etc.) and activity (e.g. working full-time vs. part-time) among providers (Birch et al., 2007).

Relevant Citations:

Birch S, Kephart G, Tomblin Murphy G, O’Brien-Pallas L, Alder R, MacKenzie, A. (2009). Health human resources planning and the production of health: Development of an extended analytical framework for needs-based health human resources planning. Journal of Public Health Management Practice, (Suppl):S56-S61.

Service-Based HHR Planning

Based on the conceptual and analytical frameworks, Collaborating Centre team members developed a practical approach to HHR planning that is based on the specific competencies of the workforce. The approach involves estimating and comparing two quantities—the number and type of specific competencies required of the health workforce to meet the health needs of the population it serves, and the number and type of those competencies that are available from the existing HHR supply.  A competency-based approach to HHR planning is of particular benefit to planners challenged to make optimal use of limited resources as it allows them to move beyond simply estimating numbers of certain professionals required and plan instead according to the unique mix of competencies available from the existing health workforce.

NB: A mention should be made that the terms ‘service-based’ and ‘competency-based’ are interchangeable; earlier publications refer more to latter and more recent ones to the former as language around HHR evolves.

Service-Based Health Human Resources Planning Framework

The service-based approach has been successfully employed in a variety of planning contexts, including aging populations, rural/remote populations, and during surge conditions such as an influenza pandemic. These can be found in both the current and previous projects sections.

Simulation Modelling

Based on the conceptual and analytical frameworks, the team has developed a simulation modeling approach to estimate and compare the available supply of HHR with the needs-based requirement for them while allowing policy makers to ‘rehearse’ potential policy changes aimed at matching these quantities.

The Collaborating Centre team has worked with decision makers in Canada, Zambia, Brazil and Jamaica to develop and/or advise on the development of simulation models for a variety of projects. These countries differ widely in size and in the structure of their political, economic, social, and cultural makeup. In collaboration with local experts, this approach has built country-specific needs-based simulation models to reflect this diversity. Subsequent years of this work will phase in the application of the model to the health care system in other countries of the Americas and of Africa.

The Simulation Model

Tomblin Murphy G, MacKenzie A, Alder R, Birch S, Kephart G, O’Brien-Pallas L. (2009). An Applied Simulation Model for Estimating the Supply of and Requirements for Registered Nurses Based on Population Health Needs. Policy, Politics and Nursing Practice; 10(4):240-251.
The Author(s) 2009 Reprints and permission:

Thus instead of looking at workforce gaps as merely being a headcount dearth, looking at many of the framework outlined supply factors allows policy makers to make projections based on improving many of these factors to better inform their decision making. For example, note the below example that looked at the combined effects of complementary policy effects to mitigate a Canadian Registered Nurse shortage.

Combined effects of various policy scenarios on simulated Canadian RN gap

G. Tomblin Murphy et al. / Health Policy 105 (2012) 192–202

Health Care Sustainability Framework

Health Care Sustainability Framework

The Health Care Sustainability Framework is based on disaggregating the health care expenditure into separate planning components. Unlike other approaches to planning health care expenditure, this framework explicitly incorporates population health needs as a determinant of health care requirements, and provides a diagnostic tool for understanding the sources of expenditure increase.

Financial sustainability is affected by revenues to support the health care system (column 4) and levels of expenditure (column 2). In difficult economic times the opportunity to support increasing expenditure through increasing revenues is constrained (column 4), leaving expenditure controls as the main tool for financial sustainability. Column 1 identifies the determinants of expenditure. The ways policies and strategies to control public health care expenditure growth affect these determinants appear in column 2. Demography and epidemiology largely lie outside the influence of health care policy, at least in the short term, leaving the shaded expenditure determinants, levels of service, provider productivity and provider pay, as policy routes for expenditure control in response to exogenous changes in population size, age distribution and health. These policies may also affect access to publicly funded health care and social inequalities in health (column 2). Reductions in access to care would threaten political sustainability (column 3) as more people seek health care from the private sector. If those with the potential ability to pay privately for care, either out of pocket or through private insurance, demand access to an alternative system, support for the publicly funded system is eroded.

The HCSF represents a development of the needs-based health workforce planning framework described by Birch et al. (2007), and is consistent with the activity analysis planning framework used effectively to analyse health workforce policy, health care expenditure policy and physician practice pattern changes (Evans, 1984). The HCSF, by drawing on these separate approaches, identifies total health care expenditure as the product of the number of health care services delivered and the average cost per service. The total number of services is determined by the product of the size of the population served, the average level of health among the population, and the average service use per person by level of health. The average cost per service is given by the product of the average provider payment per service and the average number of services delivered per provider, plus any non-direct labour costs (i.e. management and administration, capital or consumables). In other words, total health care expenditure is a function of the size and level of the health of the population, the services they use, the providers required to deliver those services, the costs of paying those providers, and any additional non-labour costs. By combining the frameworks of Evans and Birch et al. in this way, the contributions of each determinant of expenditure can be analysed and compared and the effect of policies on those determinants evaluated. The framework can be used prospectively as a planning tool to explore the resource consequences of policy developments covering, inter alia, service enhancements for particular client groups, implications of productivity improvements and provider substitution for health workforce requirements as well as expenditure consequences of these developments. It can also be used as a diagnostic tool by identifying the underlying contributing sources of expenditure growth: increases in population size, needs, services per unit need, or reductions in provider productivity and pay.

Related Publication: Birch S, Tomblin Murphy G, Cumming J, MacKenzie A. (2014). In place of fear: Aligning health care planning with system objectives to achieve financial sustainability. Journal of Health Services Research and Policy, 2015; 20(2):109-114. (OnlineFirst, published on December 11, 2014, doi:10.1177/ 1355819614562053, 1-6).

© Copyright - WHO/PAHO Collaborating Centre on Health Workforce Planning & Research