The layered crisis of the primary care medical workforce in the European region: what evidence do we need to identify causes and solutions?

Primary care services are key to population health and for the efficient and equitable organisation of national health systems. This is why they are often financed through public funds. Primary care doctors are instrumental for the delivery of preventive services, continuity of care, and for the referral of patients through the system. These cadres are also the single largest health expenditure at the core of such services. Although recruitment and retention of primary care doctors have always been challenging, shortages are now exacerbated by higher demand for services from aging populations, increased burden of chronic diseases, backlogs from the COVID-19 pandemic, and patient expectations. At the same time, the supply of primary care physicians is constrained by rising retirement rates, internal and external migration, worsening working conditions, budget cuts, and increased burnout. Misalignment between national education sectors and labour markets is becoming apparent, compounding staff shortages and maldistribution. With their predominantly publicly funded health systems and in the aftermath of COVID-19, countries of the European region appear to be now on the cusp of a multi-layered, slow-burning primary care crisis, with almost every country reporting long waiting lists for doctor appointments, shortages of physicians, unfilled vacancies, and consequently, added pressures on hospitals' Accident and Emergency services. This articles collection aims at pulling together the evidence from countries of the European Region on root causes of such workforce crisis, impacts, and effectiveness of existing policies to mitigate it. Original research is needed, offering analysis and fresh insights into the primary care medical workforce crisis in wider Europe. Ultimately, the aim of this articles collection is to provide an evidence basis for the identification of policy solutions to present and future primary health care crises in high as well as lower-income countries.

Achieving universal health coverage and sustainable development goals by 2030: investment estimates to increase production of health professionals in India.

BACKGROUND: COVID-19 has reinforced the importance of having a sufficient, well-distributed and competent health workforce. In addition to improving health outcomes, increased investment in health has the potential to generate employment, increase labour productivity and foster economic growth. We estimate the required investment for increasing the production of the health workforce in India for achieving the UHC/SDGs. METHODS: We used data from National Health Workforce Account 2018, Periodic Labour Force Survey 2018-19, population projection of Census of India, and government documents and reports. We distinguish between total stock of health professionals and active health workforce. We estimated current shortages in the health workforce using WHO and ILO recommended health worker:population ratio thresholds and extrapolated the supply of health workforce till 2030, using a range of scenarios of production of doctors and nurses/midwives. Using unit costs of opening a new medical college/nursing institute, we estimated the required levels of investment to bridge the potential gap in the health workforce. RESULTS: To meet the threshold of 34.5 skilled health workers per 10 000 population, there will be a shortfall of 0.16 million doctors and 0.65 million nurses/midwives in the total stock and 0.57 million doctors and 1.98 million nurses/midwives in active health workforce by the year 2030. The shortages are higher when compared with a higher threshold of 44.5 health workers per 10 000 population. The estimated investment for the required increase in the production of health workforce ranges from INR 523 billion to 2 580 billion for doctors and INR 1 096 billion for nurses/midwives. Such investment during 2021-2025 has the potential of an additional employment generation within the health sector to the tune of 5.4 million and to contribute to national income to the extent of INR 3 429 billion annually. CONCLUSION: India needs to significantly increase the production of doctors and nurses/midwives through investing in opening up new medical colleges. Nursing sector should be prioritized to encourage talents to join nursing profession and provide quality education. India needs to set up a benchmark for skill-mix ratio and provide attractive employment opportunities in the health sector to increase the demand and absorb the new graduates.

Adopting workload-based staffing norms at public sector health facilities in Bangladesh: evidence from two districts.

BACKGROUND: Bangladesh's Health system is characterized by severe shortage and unequitable distribution of the formally trained health workforce. In this context, government of Bangladesh uses fixed staffing norms for its health facilities. These norms do not always reflect the actual requirement in reality. This study was conducted in public sector health facilities in two selected districts to assess the existing staffing norms with the purpose of adopting better norms and a more efficient utilization of the existing workforce. METHODS: To carry out this assessment, WHO's Workload Indicators of Staffing Need (WISN) method was applied. Selection of the two districts out of 64 and a total of 24 health facilities were made in consultation with the formally established steering committee of the Ministry of Health. Health facilities, which were performing well in serving the patients during 2016-2017, were selected. This assessment examined staffing requirement of 20 staff categories. RESULTS: Based on the computer-generated WISN results, most of the staff categories were found to have a workload pressure of Very High (seven out of 20 staff categories), followed by Extremely High (five staff categories). Two staff categories had high, three had moderately high, two normal, and one low workload. Nurses were found to be predominantly occupied with support activities (50-60% of working time), instead of actual nursing care. Regarding vacancy, if all the vacant posts were filled, understandably, the workload would reduce, but not yet sufficient to meet the existing staff requirements such as consultants, general physicians and nurses at the district and sub-district/upazila-based hospitals. CONCLUSION: The existing staffing norms fall short of the WISN staffing requirement. The results provide evidence to prompt a revisit of the staffing policies and adopt workload-based norms. This can be supplemented by reviewing the scope of practice of the staff categories in their respective health facilities. In the short term, government might consider redistributing existing workforce as per workload. In the long term, revision of staffing norms is needed to provide quality health services for all.

Assessing competence of mid-level providers delivering primary health care in India: a clinical vignette-based study in Chhattisgarh state.

BACKGROUND: The global commitment to primary health care (PHC) has been reconfirmed in the declaration of Astana, 2018. India has also seen an upswing in national commitment to implement PHC. Health and wellness centres (HWCs) have been introduced, one at every 5000 population, with the fundamental purpose of bringing a comprehensive range of primary care services closer to where people live. The key addition in each HWC is of a mid-level healthcare provider (MLHP). Nurses were provided a 6-month training to play this role as community health officers (CHOs). But no assessments are available of the clinical competence of this newly inducted cadre for delivering primary care. The current study was aimed at providing an assessment of competence of CHOs in the Indian state of Chhattisgarh. METHODS: The assessment involved a comparison of CHOs with rural medical assistants (RMAs) and medical officers (MO), the two main existing clinical cadres providing primary care in Chhattisgarh. Standardized clinical vignettes were used to measure knowledge and clinical reasoning of providers. Ten ailments were included, based on primary care needs in Chhattisgarh. Each part of clinical vignettes was standardized using expert consultations and standard treatment guidelines. Sample size was adequate to detect 15% difference between scores of different cadres and the assessment covered 132 CHOs, 129 RMAs and 50 MOs. RESULTS: The overall mean scores of CHOs, RMAs and MOs were 50.1%, 63.1% and 68.1%, respectively. They were statistically different (p < 0.05). The adjusted model also confirmed the above pattern. CHOs performed well in clinical management of non-communicable diseases and malaria. CHOs also scored well in clinical knowledge for diagnosis. Around 80% of prescriptions written by CHOs for hypertension and diabetes were found correct. CONCLUSION: The non-physician MLHP cadre of CHOs deployed in rural facilities under the current PHC initiative in India exhibited the potential to manage ambulatory care for illnesses. Continuous training inputs, treatment protocols and medicines are needed to improve performance of MLHPs. Making comprehensive primary care services available close to people is essential to PHC and well-trained mid-level providers will be crucial for making it a reality in developing countries.

Implementing a health labour market analysis to address health workforce gaps in a rural region of India.

BACKGROUND: Human Resources for Health (HRH) are essential for making meaningful progress towards universal health coverage (UHC), but health systems in most of the developing countries continue to suffer from serious gaps in health workforce. The Global Strategy on Human Resources for Health-Workforce 2030, adopted in 2016, includes Health Labor Market Analysis (HLMA) as a tool for evidence based health workforce improvements. HLMA offers certain advantages over the traditional approach of workforce planning. In 2018, WHO supported a HLMA exercise in Chhattisgarh, one of the predominantly rural states of India. METHODS: The HLMA included a stakeholder consultation for identifying policy questions relevant to the context. The HLMA focused on state HRH at district-level and below. Mixed methods were used for data collection and analysis. Detailed district-wise data on HRH availability were collected from state's health department. Data were also collected on policies implemented on HRH during the 3 year period after the start of HLMA and changes in health workforce. RESULTS: The state had increased the production of doctors but vacancies persisted until 2018. The availability of doctors and other qualified health workers was uneven with severe shortages of private as well as public HRH in rural areas. In case of nurses, there was a substantial production of nurses, particularly from private schools, however there was a lack of trusted accreditation mechanism and vacancies in public sector persisted alongside unemployment among nurses. Based on the HLMA, pragmatic recommendations were decided and followed up. Over the past 3 years since the HLMA began an additional 4547 health workers including 1141 doctors have been absorbed by the public sector. The vacancies in most of the clinical cadres were brought below 20%. CONCLUSION: The HLMA played an important role in identifying the key HRH gaps and clarifying the underlying issues. The HLMA and the pursuant recommendations were instrumental in development and implementation of appropriate policies to improve rural HRH in Chhattisgarh. This demonstrates important progress on key 2030 Global Strategy milestones of reducing inequalities in access to health workers and improving financing, retention and training of HRH.

Informing investment in health workforce in Bangladesh: a health labour market analysis.

BACKGROUND: As the 2016 Global Strategy on Human Resources for Health: Workforce 2030 (GSHRH) outlines, health systems can only function with health workforce (HWF). Bangladesh is committed to achieving universal health coverage (UHC) hence a comprehensive understanding of the existing HWF was deemed necessary informing policy and funding decisions to the health system. METHODS: The health labour market analysis (HLMA) framework for UHC cited in the GSHRH was adopted to analyse the supply, need and demand of all health workers in Bangladesh. Government's information systems provided data to document the public sector HWF. A national-level assessment (2019) based on a country representative sample of 133 geographical units, served to estimate the composition and distribution of the private sector HWF. Descriptive statistics served to characterize the formal and informal HWF. RESULTS: The density of doctors, nurses and midwives in Bangladesh was only 9.9 per 10 000 population, well below the indicative sustainable development goals index threshold of 44.5 outlined in the GSHRH. Considering all HWFs in Bangladesh, the estimated total density was 49 per 10 000 population. However, one-third of all HWFs did not hold recognized roles and their competencies were unknown, taking only qualified and recognized HWFs into account results in an estimated density 33.2. With an estimate 75 nurses per 100 doctors in Bangladesh, the second area, where policy attention appears to be warranted is on the competencies and skill-mix. Thirdly, an estimated 82% of all HWFs work in the private sector necessitates adequate oversight for patient safety. Finally, a high proportion of unfilled positions in the public sector, especially in rural areas where 67% of the population lives, account only 11% of doctors and nurses. CONCLUSION: Bangladesh is making progress on many of the milestones of the GSHRH, notably, the establishment of the HWF unit and reporting through the national health workforce accounts. However, particular investment on strengthening the intersectoral HWF coordination across sectors; regulation for assurance of patient safety and adequate oversight of the private sector; establishing accreditation mechanisms for training institutions; and halving inequalities in access to a qualified HWF are important towards advancing UHC in Bangladesh.

Size, composition and distribution of health workforce in India: why, and where to invest?

BACKGROUND: Investment in human resources for health not only strengthens the health system, but also generates employment and contributes to economic growth. India can gain from enhanced investment in health workforce in multiple ways. This study in addition to presenting updated estimates on size and composition of health workforce, identifies areas of investment in health workforce in India. METHODS: We analyzed two sources of data: (i) National Health Workforce Account (NHWA) 2018 and (ii) Periodic Labour Force Survey 2017-2018 of the National Sample Survey Office (NSSO). Using the two sources, we collated comparable estimates of different categories of health workers in India, density of health workforce and skill-mix at the all India and state levels. RESULTS: The study estimated (from NHWA 2018) a total stock of 5.76 million health workers which included allopathic doctors (1.16 million), nurses/midwives (2.34 million), pharmacist (1.20 million), dentists (0.27 million), and traditional medical practitioner (AYUSH 0.79 million). However, the active health workforce size estimated (NSSO 2017-2018) is much lower (3.12 million) with allopathic doctors and nurses/midwives estimated as 0.80 million and 1.40 million, respectively. Stock density of doctor and nurses/midwives are 8.8 and 17.7, respectively, per 10,000 persons as per NHWA. However, active health workers' density (estimated from NSSO) of doctor and nurses/midwives are estimated to be 6.1 and 10.6, respectively. The numbers further drop to 5.0 and 6.0, respectively, after accounting for the adequate qualifications. All these estimates are well below the WHO threshold of 44.5 doctor, nurses and midwives per 10,000 population. The results reflected highly skewed distribution of health workforce across states, rural-urban and public-private sectors. A substantial proportion of active health worker were found not adequately qualified on the one hand and on the other more than 20% of qualified health professionals are not active in labor markets. CONCLUSION: India needs to invest in HRH for increasing the number of active health workers and also improve the skill-mix which requires investment in professional colleges and technical education. India also needs encouraging qualified health professionals to join the labor markets and additional trainings and skill building for already working but inadequately qualified health workers.

The health workforce: Central to an effective response to the COVID-19 pandemic in the European Region.

COVID-19 has reinforced the centrality of health workers at the core of a well performing and resilient health system. It has concomitantly exposed the risks of staffing and skills shortages and the importance of protecting the health workforce. The present commentary focuses on highlighting some of the lessons learnt, challenges and future needs of the health workforce in Europe in the context of COVID-19. During the pandemic innovative and flexible approaches were implemented to meet increasing demand for health workers and new skills and responsibilities were adopted over a short period of time. We have seen the rapid adaptation and use of new technologies to deliver care. The pandemic has underlined the importance of valuing, protecting and caring for our health workforce and the need to invest appropriately and adequately in the health workforce to have sufficient, capable and well-motivated health workers. Some of the main challenges that lie ahead of us include the imperative for better investment, to need to improve recruitment and retraining whilst better retaining health workers, a focus on domestic sustainability, redeploying and developing new skills and competences among health workers, enabling more effective multi-professional collaboration and team work, improving the quality of education and training, increasing the public health focus and promoting ethical and sustainable international recruitment of health workers. The WHO European Region through its European Programme of Work 2020-2025 is fully committed to support countries in their efforts to continue to respond to COVID-19 and whilst addressing upcoming health workforce challenges.

Analysing public sector institutional capacity for health workforce governance in the South-East Asia region of WHO.

BACKGROUND: In order to analyse the institutional capacity for health workforce policy development and implementation in countries in the South-East Asia region, the WHO facilitated a cross-sectional analysis of functions performed, structure, personnel, management and information systems of human resources for health (HRH) units in Ministries of Health. CASE PRESENTATION: A self-assessment survey on the characteristics and roles of HRH units was administered to relevant Government officials; the responses were validated through face-to-face workshops and by the WHO staff. Findings were tabulated to produce frequency distributions of the variables examined, and qualitative elements categorized according to a framework for capacity building in the health sector. Ten countries out of the 11 in the region responded to the survey. Seven out of 10 reported having an HRH unit, though their scope, roles, capacity and size displayed considerable variability. Some functions (such as planning and health workforce data management) were reportedly carried out in all countries, while others (inter-sectoral coordination, research, labour relations) were only performed in few. DISCUSSION AND CONCLUSIONS: The strengthening of the HRH governance capacity in countries should follow a logical hierarchy, identifying first and foremost the essential functions that the public sector is expected to perform to optimize HRH governance. The definition of expected roles and functions will in turn allow identifying the upstream system-wide factors and the downstream capacity requirements for the strengthening of the HRH units. The focus should ultimately be on ensuring that all the key strategic functions are performed to quality standards, irrespective of institutional arrangements.

The global effect of digital health technologies on health workers' competencies and health workplace: an umbrella review of systematic reviews and lexical-based and sentence-based meta-analysis.

Systematic reviews have quantified the effectiveness, feasibility, acceptability, and cost-effectiveness of digital health technologies (DHTs) used by health-care workers. We aimed to collate available evidence on technologies' effect on health-care workers' competencies and performance. We searched the Cochrane Database of Systematic Reviews, Embase, MEDLINE, Epistemonikos, and Scopus for reviews published from database inception to March 1, 2023. Studies assessing the effects of DHTs on the organisational, socioeconomic, clinical, and epidemiological levels within the workplace, and on health-care workers' performance parameters, were included. Data were extracted and clustered into 25 domains using vote counting based on the direction of effect. The relative frequency of occurrence (RFO) of each domain was estimated using R software. AMSTAR-2 tool was used to appraise the quality of reporting, and the Confidence in the Evidence from Reviews of Qualitative research approach developed by Grading of Recommendations Assessment, Development and Evaluation was used to analyse the certainty of evidence among included studies. The 12 794 screened reviews generated 132 eligible records for assessment. Top-ranked RFO identifiers showed associations of DHT with the enhancement of health-care workers' performance (10·9% [95% CI 5·3-22·5]), improvement of clinical practice and management (9·8% [3·9-24·2]), and improvement of care delivery and access to care (9·2% [4·1-20·9]). Our overview found that DHTs positively influence the daily practice of health-care workers in various medical specialties. However, poor reporting in crucial domains is widely prevalent in reviews of DHT, hindering our findings' generalisability and interpretation. Likewise, most of the included reviews reported substantially more data from high-income countries. Improving the reporting of future studies and focusing on low-income and middle-income countries might elucidate and answer current knowledge gaps.

Barriers and facilitators to utilizing digital health technologies by healthcare professionals.

Digital technologies change the healthcare environment, with several studies suggesting barriers and facilitators to using digital interventions by healthcare professionals (HPs). We consolidated the evidence from existing systematic reviews mentioning barriers and facilitators for the use of digital health technologies by HP. Electronic searches were performed in five databases (Cochrane Database of Systematic Reviews, Embase®, Epistemonikos, MEDLINE®, and Scopus) from inception to March 2023. We included reviews that reported barriers or facilitators factors to use technology solutions among HP. We performed data abstraction, methodological assessment, and certainty of the evidence appraisal by at least two authors. Overall, we included 108 reviews involving physicians, pharmacists, and nurses were included. High-quality evidence suggested that infrastructure and technical barriers (Relative Frequency Occurrence [RFO] 6.4% [95% CI 2.9-14.1]), psychological and personal issues (RFO 5.3% [95% CI 2.2-12.7]), and concerns of increasing working hours or workload (RFO 3.9% [95% CI 1.5-10.1]) were common concerns reported by HPs. Likewise, high-quality evidence supports that training/educational programs, multisector incentives, and the perception of technology effectiveness facilitate the adoption of digital technologies by HPs (RFO 3.8% [95% CI 1.8-7.9]). Our findings showed that infrastructure and technical issues, psychological barriers, and workload-related concerns are relevant barriers to comprehensively and holistically adopting digital health technologies by HPs. Conversely, deploying training, evaluating HP's perception of usefulness and willingness to use, and multi-stakeholders incentives are vital enablers to enhance the HP adoption of digital interventions.

Assessing capacities and resilience of health services during the COVID-19 pandemic: Lessons learned from use of rapid key informant surveys.

This article is part of the Research Topic: 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict.' Problem: Many countries lacked rapid and nimble data systems to track health service capacities to respond to COVID-19. They struggled to assess and monitor rapidly evolving service disruptions, health workforce capacities, health products availability, community needs and perspectives, and mitigation responses to maintain essential health services. Method: Building on established methodologies, the World Health Organization developed a suite of methods and tools to support countries to rapidly fill data gaps and guide decision-making during COVID-19. The tools included: (1) a national "pulse" survey on service disruptions and bottlenecks; (2) a phone-based facility survey on frontline service capacities; and (3) a phone-based community survey on demand-side challenges and health needs. Use: Three national pulse surveys revealed persisting service disruptions throughout 2020-2021 (97 countries responded to all three rounds). Results guided mitigation strategies and operational plans at country level, and informed investments and delivery of essential supplies at global level. Facility and community surveys in 22 countries found similar disruptions and limited frontline service capacities at a more granular level. Findings informed key actions to improve service delivery and responsiveness from local to national levels. Lessons learned: The rapid key informant surveys provided a low-resource way to collect action-oriented health services data to inform response and recovery from local to global levels. The approach fostered country ownership, stronger data capacities, and integration into operational planning. The surveys are being evaluated to inform integration into country data systems to bolster routine health services monitoring and serve as health services alert functions for the future.

Assessment of staffing needs for physicians and nurses at Upazila health complexes in Bangladesh using WHO workload indicators of staffing need (WISN) method.

OBJECTIVE: This study aimed to assess the current workload and staffing need of physicians and nurses for delivering optimum healthcare services at the Upazila Health Complexes (UpHCs) in Bangladesh. DESIGN: Mixed-methods, combining qualitative (eg, document reviews, key informant interviews, in-depth interviews, observations) and quantitative methods (time-motion survey). SETTING: Study was conducted in 24 health facilities of Bangladesh. However, UpHCs being the nucleus of primary healthcare in Bangladesh, this manuscript limits itself to reporting the findings from the providers at four UpHCs under this project. PARTICIPANTS: 18 physicians and 51 nurses, males and females. PRIMARY OUTCOME MEASURES: Workload components were defined based on inputs from five experts, refined by nine service providers. Using WHO Workload Indicator of Staffing Need (WISN) software, standard workload, category allowance factor, individual allowance factor, total required number of staff, WISN difference and WISN ratio were calculated. RESULTS: Physicians have very high (WISN ratio 0.43) and nurse high (WISN ratio 0.69) workload pressure. 50% of nurses' time are occupied with support activities, instead of nursing care. There are different workloads among the same staff category in different health facilities. If only the vacant posts are filled, the workload is reduced. In fact, sanctioned number of physicians and nurses is more than actual need. CONCLUSIONS: It is evident that high workload pressures prevail for physicians and nurses at the UpHCs. This reveals high demand for these health workforces in the respective subdistricts. WISN method can aid the policy-makers in optimising utilisation of existing human resources. Therefore, the government should adopt flexible health workforce planning and recruitment policy to manage the patient load and disease burden. WISN should, thus, be incorporated as a planning tool for health managers. There should be a regular review of health workforce management decisions, and these should be amended based on periodic reviews.