Patrici a Riley, CNM, MPH, FACNM, CAPT (Ret) Division of Global HIV/AIDS

1. Information Systems to Monitor Human Resources for Health: A Systematic Review Patricia Riley, CNM, MPH, FACNM, CAPT (Ret) Division of Global HIV/AIDS Centers for Disease Control and Prevention Nursing Recognition Day May 3, 2013 Center for Global Health Division of Global HIV /AIDS

2. Why is this important?

3. BACKGROUND/ RATIONALE

4. Background/ Rationale • Builds on 10 years of work developing a comprehensive workforce information system in Kenya • HR information systems (HRIS) are a critical tool to help MOH and other stakeholders target scarce resources to scale-up and retain health workers • Significant global investment in HR information systems (HRIS) by major global health initiatives • Need for a systematic review of approaches to HRIS to help develop an evidence -base to guide HRIS implementation globally in HRH “crises” vs. non-crises countries

5. Overview of HRIS • HR information systems (HRIS): a routine system for tracking the supply and deployment of the health workforce for strategic and operational health and HR decision-making HRH Managers- MOH, private, non-profit, and faith-based sectors Professional Regulatory Bodies Payroll Pre-service institutions HMIS All Provinces Routine Census/ Labor Force Surveys All Districts Workforce Supply Workforce Demand Other Data

6. OBJECTIVES

7. OBJECTIVES • Review and systematically characterize the implementation of HRIS in countries around the world • Identify models and features of HRIS applicable to crisis and non-crisis countries • Offer recommendations to ministries of health and global health policy makers on how to improve the science and application of HRIS

8. METHODS

9. METHODS- Review Team CDC, Atlanta WHO, Geneva Patricia Riley Neeru Gupta Alexandra Zuber Pascal Zurn Andre Verani Nadine Sunderland Emory University Michael FriedmanStephen Vindigni Chijioke Okoro Heather Patrick Integrare, Barcelona James Campbell

10. METHODS- Peer Reviewed • Four electronic databases (1959-2009): • Medline (including in-process and non-indexed citations), • ExcerptaMedica database (EMBASE), • PsycInfo and • Cumulative Index to Nursing and Allied Health Literature (CINAHL) • Seven Bibliographic databases (1959-2009): • LILACS (Literature Latino-Americana e do Caribe emCiencias da Saude), searched in English • Global Health • Sociological Abstracts • Social Service Abstracts • ERIC (Education Resources Information Center) • Web of Science (SCI and SSCI) • Cochrane

11. METHODS- Grey Literature • 29 electronic databases and websites, in four languages (1999-2009): African Atlas of the Health Workforce Regional Core Health Data Initiative for the Americas Eastern Mediterranean Regional Observatory on Human Resources for Health European Health for All Database European Observatory on Health Systems and Policies Regional Database of Health Indicators for the Western Pacific Pacific Human Resources for Health Alliance Country Health System Profiles for the South-East Asia Region OECD Health Data Eurostat Database on Population and Social Conditions World Development Indicators LABORSTA Database UNESCO Education Statistics Database The Capacity Project’s HRH Global Res. Center WHO Africa Health Workforce Observatory Health Metrics Network Routine Health Information Network (RHINO) Public Health Informatics Institute (PHII) Google and Google Scholar Int’l Council of Nurses Innovations Database Asia-Pacific Action Alliance on HRH European Obs. on Health Systems and Policies PAHO Observatory of Human Resources PAHO-USAID Partnership, Health Systems Eastern Med. Regional Health System Obs. Eldis.net The Int’l Centre for Human Resources in Nursing Global Health Workforce Alliance Global Atlas of the Health Workforce

12. Review Process • Screening of articles • Assignment of articles to review pairs* • Abstraction tool, with guidance • Individual abstraction record • Joint abstraction record • Country composite abstraction record • Entered data into Epi-Info database • Aggregated results by WHO HR “crisis” and “non-crisis” countries • * Reviewers did not review articles for which they were listed as an author

13. Data Collection Data Management Data Utilization

14. RESULTS

15. RESULTS • 11,922 articles were initially identified in the peer reviewed and grey literature • After applying our exclusion criteria, 95 articles remained, representing HRIS from 65 countries and regions • 32 WHO-designated HRH “crisis” countries • 31 non-crisis countries • Regional systems identified in Southeast Asia, Mercosur, and the Pacific Islands

16. DOCUMENTATION OF KEY HRIS FEATURES IN COUNTRIES REVIEWED Data Mgmt Data Collection Data Utilization

17. RESULTS • General • “Unclear” was the most common response for 11 of 16 indicators displayed for crisis and non-crisis countries • No consistent reporting framework for HRIS • Expected trends in features based on economic development (crisis v. non-crisis countries) • Supply Data • A high percentage of crisis and non-crisis countries documented collecting workforce supply data generally (63% and 74%, respectively) • But collection of health worker qualifications and professional credentialing and demographic data was much more limited

18. RESULTS • Deployment Data • High percentage of crisis and non-crisis countries reported as collecting demand data generally (63% and 87%, respectively) • However, specific features of deployment data was much more limited: • Workforce Attrition: Only 23% of 65 HRIS examined explicitly collect data on workforce attrition • Private, non-profit, and faith-based sectors: documented in only 34% of HRIS reviewed (28% in crisis countries, 39% in non-crisis countries)

19. DOCUMENTATION OF KEY HRIS FEATURES IN COUNTRIES REVIEWED Data Mgmt Data Collection Data Utilization

20. RESULTS • Data Management • Linkages: 14% of countries documenting an established link between supply and deployment data, 11% linked to payroll, and 34% linked HRIS to an overall health information system • Data cleaning and accuracy: 6% of crisis countries and 19% of non-crisis countries reported methods for ensuring this component of an HRIS • Data Utilization • The use of HRIS for identifying licensed practitioners, making deployment decisions, and other planning and evaluation was limited, especially in crisis countries • Sustainability and Ownership • Notable ambiguity with respect to the sustainability, ownership, and endorsement of HRIS by local stakeholders (e.g. MOH)

21. LIMITATIONS • The review could only abstract features of HRIS that are documented in publicly available literature • Of the documented HRIS, it was frequently unclear whether specific features of an HRIS were present, absent, or lacked written description • Nearly one-half of the documents were based on HMN assessment tool for HIS, which were inconsistent in reporting HRIS features

22. DISCUSSION

23. DISCUSSION • Despite global calls to action and significant global investment in HRIS, there is a dearth of information on country experience, particularly in the peer-reviewed literature • Reporting emphasizes generation of supply and deployment data generation, but few reports of effective data management techniques and the use of this information for resource allocation and program planning

24. DISCUSSION • The small number of documented HRIS collection of demographic data prohibits basic HR planning (e.g. age trends analysis) • The lack of attrition data (e.g. outmigration) limits countries from reporting related to the WHO code of ethical recruitment • Global inability to monitor health workforce from more than one sector impedes national sector-wide health planning, which is especially important where HR is in critical shortage

25. PROMISING DOCUMENTED HRIS MODELS • Promising models were those that were well documented in the literature and whose features were well articulated. Based on a method of scoring the abstraction records, we identified the following: • Non-crisis countries: Canada, U.S., Brazil • Crisis countries: Kenya, Malawi, and Swaziland

26. RECOMMENDATIONS • Greater global consensus on standardized approaches to HRIS implementation and key features of HRIS, to improve implementation, with: • A focus on crisis countries • Emphasis on effective data management and use • Descriptive research of HRIS implementation, including promising models and key features, to understand what successful approaches work in specific health systems contexts • Consistent framework for HRIS assessment and reporting (e.g. HMN HIS tool modification)

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