Introduction

One of the greatest challenges in the healthcare field is planning the health workforce under limited financial resources while being fully capable of responding to an affordable, fair and efficient healthcare system. The Ministry of Health (MoH) Ethiopia with the support from World Health Organization (WHO) and Jhpiego conducted a pilot study using the Workload Indicator of Staffing Need (WISN) to determine the staffing level at selected health facilities. The WISN tool was developed by WHO to estimate the number of staff of a specific category, a health facility requires based on the actual workload for that facility. The main objective of the study was to determine adequate staffing level and identify gaps using the WISN methodology in selected primary, secondary and tertiary care facilities, and forecast the required staffing numbers at these health facilities towards the attainment of universal health coverage.

Methodology

The MoH led all preparatory work and implementation of this study based on terms of reference and action plans since November 2020.  All standard steps of WISN from determining health cadres and facilities to interpreting WISN results and reporting were followed. The study involved review of the literature and relevant documents, key informant interviews and annual service statistics from the hospitals' records were used to obtain data.  The study purposively selected sample health facilities from all the regions excluding Tigray and Gambella . The health facilities cut across all levels of care. A total of 72 health facilities were planned to be included in the study -14 health posts, 25 health centres, 12 primary hospitals, 16 general hospitals with 2 of them being private facilities and 4 teaching and referral hospitals and 1 highly specialized college and hospital. However, at the analysis stage only a total of 54 health facilities had substantive data for analysis based on the 7 core cadres selected for the first round of the study.

Results: The analysis was done for seven important cadres including Medical Doctors, health officer, nurses, midwives, anesthesia, laboratory and pharmacy professionals. The WISN results were provided through the difference and ratio indicators that were generated from the WISN software and described to show WISN ratios that are used to interpret workload pressure, staffing gaps or shortages, staff balances and surpluses. The results were further categorized and interpreted within the specific context and supported by the observations. The two analyses helped in examining different aspects of the staffing situation in the facilities. There were mixed results that varied from one cadre to another and from one facility to the other. Analysis at individual and similar facilities and cadres projected differences. Based on the findings, some facilities showed surplus of health workers whereas shortages were evident in others. The extent of workload pressures was also found to be varying among health facilities and professional categories which ranged from extremely high kind of workload on one hand to extremely low on the other. The WISN study showed that the existing fixed facility staffing norms is no longer fit for purpose. As per the findings of this study and considering the list of health services expected at Health post level stipulated in the EHSP, additional one Health Officer, two Midwives and one Nurse should be considered in addition to the existing two HEWs specified in the existing staffing norm. At Health Centers level, on average 15 additional mix of different professional categories included in the study are required.  Moreover, Primary Hospitals and General Hospitals on average demand a combination of additional 14 and 25 mix of cadres, except for nurses and laboratory professionals incorporated in the study respectively. Furthermore, except for nursing professionals, Referral/Teaching Hospitals on average require additional 63 mix of different professional categories involved in the assessment. The study also explored the budgetary implication for the additional staff requirements across the tiered health system. About 12.6 Billion Birr (USD 378,586,100) * additional budget is required in 2021 to cover the cost of employment. (US$1 = 33.25 Birr)

Recommendations: The study recommended several short term , midterm and long-term recommendations some of them  include redeployment of staff from health facilities with surpluses and extremely low workloads pressures to health facilities with significant shortages and high workload pressure, use the findings to the recently planned revision of staffing standard,  standardize health services provided in similar health centers at the same level of care, Review some scopes of work and practice and subsequently job descriptions for the subcategories of staff whose roles overly overlap, Classify and reclassify some health facilities based on workloads and service packages, strengthen HWF production capacity , review some of the HRH practices and service delivery models