Lessons learned from implementation of the Workload Indicator of Staffing Need (WISN) methodology: an international Delphi study of expert users.

BACKGROUND: Staffing of health services ought to consider the workload experienced to maximize efficiency. However, this is rarely the case, due to lack of an appropriate approach. The World Health Organization (WHO) developed and has promoted the Workload Indicators of Staffing Need (WISN) methodology globally. Due to its relative simplicity compared to previous methods, the WISN has been used extensively, particularly after its computerization in 2010. Many lessons have been learnt from the introduction and promotion of the methodology across the globe but have, hitherto, not been synthesized for technical and policy consideration. This study gathered, synthesized, and now shares the key adaptations, innovations, and lessons learned. These could facilitate lesson-learning and motivate the WHO's WISN Thematic Working Group to review and further ease its application. METHODS: The study aimed to answer four questions: (1) how easy is it for the users to implement each step of the WISN methodology? (2) What innovations have been used to overcome implementation challenges? (3) What lessons have been learned that could inform future WISN implementation? and (4) what recommendations can be made to improve the WISN methodology? We used a three-round traditional Delphi method to conduct a case study of user-experiences during the adoption of the WISN methodology. We sent three email iterations to 23 purposively selected WISN expert users across 21 countries in five continents. Thematic analysis of each round was done simultaneously with data collection. RESULTS: Participants rated seven of the eight technical steps of the WISN as either "very easy" or "easy" to implement. The step considered most difficult was obtaining the Category Allowance Factors (CAF). Key lessons learned were that: the benefits gained from applying the WISN outweigh the challenges faced in understanding the technical steps; benchmarking during WISN implementation saves time; data quality is critical for successful implementation; and starting with small-scale projects sets the ground better for more effective scale-up than attempting massive national application of the methodology the first time round. CONCLUSIONS: The study provides a good reference for easing WISN implementation for new users and for WHO to continue promoting and improving upon it.

Making the transition to workload-based staffing: using the Workload Indicators of Staffing Need method in Uganda.

BACKGROUND: Uganda's health workforce is characterized by shortages and inequitable distribution of qualified health workers. To ascertain staffing levels, Uganda uses fixed government-approved norms determined by facility type. This approach cannot distinguish between facilities of the same type that have different staffing needs. The Workload Indicators of Staffing Need (WISN) method uses workload to determine number and type of staff required in a given facility. The national WISN assessment sought to demonstrate the limitations of the existing norms and generate evidence to influence health unit staffing and staff deployment for efficient utilization of available scarce human resources. METHODS: A national WISN assessment (September 2012) used purposive sampling to select 136 public health facilities in 33/112 districts. The study examined staffing requirements for five cadres (nursing assistants, nurses, midwives, clinical officers, doctors) at health centres II (n = 59), III (n = 53) and IV (n = 13) and hospitals (n = 11). Using health management information system workload data (1 July 2010-30 June 2011), the study compared current and required staff, assessed workload pressure and evaluated the adequacy of the existing staffing norms. RESULTS: By the WISN method, all three types of health centres had fewer nurses (42-70%) and midwives (53-67%) than required and consequently exhibited high workload pressure (30-58%) for those cadres. Health centres IV and hospitals lacked doctors (39-42%) but were adequately staffed with clinical officers. All facilities displayed overstaffing of nursing assistants. For all cadres at health centres III and IV other than nursing assistants, the fixed norms or existing staffing or both fell short of the WISN staffing requirements, with, for example, only half as many nurses and midwives as required. CONCLUSIONS: The WISN results demonstrate the inadequacies of existing staffing norms, particularly for health centres III and IV. The results provide an evidence base to reshape policy, adopt workload-based norms, review scopes of practice and target human resource investments. In the near term, the government could redistribute existing health workers to improve staffing equity in line with the WISN results. Longer term revision of staffing norms and investments to effectively reflect actual workloads and ensure provision of quality services at all levels is needed.

Utilisation of Community Audio Towers in Health Education for Prevention of Cervical Cancer by Health Workers in Kyotera District, Uganda: A Cross-Sectional Study.

PURPOSE: Community audio towers (CATs) are a communication resource that can be utilized by public health practitioners to enhance health communication in rural and peri-urban settings. However, information on availability of this channel of communication for use in health education and promotion remains scanty. We determined the availability of CATs for use in cervical cancer health education among health workers for prevention of cervical cancer in Kyotera District, Uganda. METHODS: Using a cross-sectional study design, health workers were randomly selected from health facilities in Kyotera District. Eligible participants were health workers who had worked in the district for at least one year. A pre-tested study questionnaire was self-administered. Descriptive statistics were used to determine availability and use of CATs, while factors associated with the use of CATs were determined by logistic regression analysis. RESULTS: Between March and April 2020, 160 health workers were enrolled, and of these, 102 (63.8%) were females and 69 (43.1%) were nurses. Most of them, ie, 143 (89.4%) reported that CATs were within walkable distance from their workplaces; 140 (87.5%) indicated that CATs are conveniently located, and 129 (80.6%) reported that it was easy to secure airtime to sensitise communities on health issues. Only 26 (16.3%) had ever used CATs for cervical cancer health education. Health workers at facilities without a plan that includes CATs as a channel of health communication were less likely to utilise CATs (OR = 0.04, 95% CI (0.0043-0.37), p = 0.005) while those who had ever managed a patient with cervical cancer (OR = 16.48, 95% CI (3.4-79.7), p < 0.001) were more likely to utilise CATs. CONCLUSION: Although CATs were deemed readily available, there was low utilisation for cervical cancer education and promotion of preventive services by health workers. Health facilities need to strategically include CATs in their plans to increase utilisation.