Evidence Based Human Resource for Health (HRH) Planning: Workload Indicators of Staffing Need (WISN) application at Public Sector Health Facilities

A significant number of vacant positions exist at all levels of facilities, including community levels. The workload of health service providers, expressed in terms of the Workload Indicators of Staffing Need (WISN) ratio, is high at most facilities and community levels in the study area. Direct health service providers, such as physicians and nurses, spend a substantial proportion of their available working time (AWT) on support and additional activities rather than on health care delivery. Physicians at district hospitals and Upazila Health Complexes (UHC) spend 29-34% of AWT on support and additional activities, while nurses spend 72-78% of AWT on support services and additional services. This indicates that a significant portion of their time is devoted to tasks beyond their specific job assignments. Inequalities in workload are observed among the same category of staff working at different-level facilities as well as among same-level facilities. The WISN ratio for nurses at district hospitals ranged from 0.43-0.5, indicating that only 43-50% of the required number of nurses are available. At UHCs, the ratio ranged from 0.3-0.71 (30-73%). The WISN ratio for physicians ranged between 0.36-0.58 at district hospitals and 0.4-1.21 at UHCs. Support services staff, such as cleaning, laundry, attending, kitchen, and security staff, are also crucial for the optimum functioning of health facilities. However, there is a substantial shortage of nearly all categories of support staff. The requirement of support staff based on workload is not given the same priority as clinically relevant human resources or direct service providers. However, support services are essential for the effective functioning of health facilities. The study sites included 2 District Hospitals, 2 District-level Maternal and Child Welfare Centres, 4 Upazila Health Complexes, 8 Union-level Facilities, and 4 Community Clinics. The selected sites were defined as "model" sites, which had better performance as evidenced by certain indicators available in the Management Information System (MIS). The study aimed to understand the existing workload of different categories of health workforce engaged in providing preventive, promotional, or curative services at health facilities and in communities at district levels and below. The Workload Indicators of Staffing Need (WISN) method was customized for the Bangladesh context. The study involved two phases: Phase I, which defined workload components and set activity (time) standards through in-depth discussions with experts and experienced practitioners at facilities and in the field; and Phase II, which assessed staffing need in various levels of public sector healthcare through confirming workload components and activity standards with key personnel at study facilities, matching time standards with findings from direct observations, collecting annual service statistics and human resources data from facilities, and cross-checking data with national-level HMIS and HRIS. The WISN method is a human resource management tool that assesses the work pressure of health workers in a facility and determines how many health workers of a particular type are required to cope with the workload of a given health facility. The method allows health managers to systematically make staffing decisions. WISN results are analyzed in two ways: difference, which identifies health facilities that are relatively understaffed or overstaffed by comparing the difference between current and required number of staff; and ratio, which assesses the work pressure that health workers experience in their daily work in a health facility by a proxy measure 'WISN Ratio'.