Background: The equitable distribution of a skilled health workforce is critical to health service delivery. Kaduna state has taken significant steps to revamp the primary health care system to ensure access to health care for its populace. However, these investments are yet to yield the desired outcomes due to health workforce shortages and the inequitable distribution of those available. Methods: A Workload Indicator for Staffing Need (WISN) study was conducted at Kaduna state’s primary health care level. The study focused on estimating staffing requirements; Nurses/Midwives and Community Health Worker practitioners, Community Health Officers, Community Health Extension Workers, and Junior Community Health Extension Workers in all government-prioritised primary health care facilities. A total of ten focal primary health care facilities in Kaduna North Local Government Area (LGA) were included in the study. Results: Findings from the study revealed a shortage of Nurses/Midwives and Community Health Workers across the study facilities. For the Nurse/Midwife staffing category, nine of the ten PHCs have a WISN ratio 1 was calculated. Conclusion: The WISN study highlights staffing needs in Kaduna State’s government-prioritised primary health care facilities. This evidence establishes the basis for applying an evidence-based approach to determining staffing needs across the primary health care sector in the State to guide workforce planning strategies and future investments in the health sector. The World Health Organisation (WHO) WISN tool is useful for estimating staffing needs required to cope with workload pressures, particularly in a resource-constrained environment like Kaduna State.
Written informed consent was obtained before data collection during the field visit through the Health Research Ethics Committee (HREC) of the Kaduna State Ministry of Health and had an approved registration number NHREC/17/03/2018. The study employed the WISN methodology to determine staffing needs. WISN is designed by the WHO and supports the evidential determination of the number of health workers by cadre required to cope with the workload in a particular health facility. The WISN methodology considers several relevant components by health worker cadre that includes: (i) services delivered, (ii) the time it takes to deliver both clinical and non-clinical services, (iii) the total annual work time available to each Health Care Workers (HCW) cadre as well as (iv) retrospective annual service delivery statistics in the health facility. 13 Computation of the statistics from these components produces a determined number of HCWs by cadre required in each health facility. The WISN study was completed in Kaduna North Local Government Area and included ten (10) primary health facilities. The study population were clinical health workers available and tasked with providing healthcare services to patients at these primary health facilities. These prioritised cadres are Nurses/Midwives and Community Health Workers (CHWs), comprising Community Health Officers (CHOs), Community Health Extension Workers (CHEWs), and Junior Community Health Extension Workers (JCHEWS). Health services such as Reproductive Maternal and Newborn Child Health (RMNCH), predominantly provided at the primary care level and make up most of the health facility visits in the LGA, were prioritised for the study. Three Technical Working Groups (TWGs): Steering Committee, Technical Task Force, and an Expert Group were inaugurated to conduct the study. These study groups were a subset of the State’s larger HRH TWG. Their objectives include providing HRH-related advisory and technical support to the State government to enable workforce development. The three group members were drawn from relevant Ministries, Departments and Agencies (MDA), health training institutions, Civil Society Organisations (CSO), health facilities and development partners. These groups were engaged to build local capacity and create utility for study results. Kaduna North Local Government Areas (LGA) was selected for convenience for this study. Consequently, all government-prioritised PHC facilities that had been in operation for at least one year before the time of the study were included. Kaduna North LGA is an urban area and one of the most densely populated areas in the State. The decision to include only government-prioritised PHC facilities is hinged on the significant investments made by the State government and donors in these facilities and a resultant increase in service utilisation rates. After a review of relevant documents that include the Nigeria Task Shifting and Task Sharing (TSTS) policy, the MSP, Ward Minimum Healthcare Package (WMHCP) and the public service handbook, data collection tools were developed. Data on health service statistics, facility HRH composition, staff Available Work Time (AWT) and time spent by healthcare workers on clinical and non-clinical activities were collected and compared from both primary and secondary sources. Primary data sources included health facility service delivery registers, staff registers, and expert judgments through an Expert Group discussion. Primary data collection lasted three weeks between June and July 2021. Secondary data sources included the Nigeria District Health Information System (DHIS2) and Kaduna State Primary Healthcare Board (KSPHCB) Human Resources for Health Information System (HRH-IS). The DHIS2 is the electronic instance of the National Health Management Information System (NHMIS), a paper-based mechanism aggregating all healthcare services delivered in a health facility. For health service statistics, data for family planning, antenatal care, postnatal care, immunization, diarrhoea, pneumonia and malaria in children and adults from January to December 2019 were obtained from health facility registers and compared with those retrieved from the DHIS2. Further, during field visits, facility workforce data focusing on clinical cadres were obtained from health facility staff registers. A multi-step approach was taken to obtain information on staff AWT (the total amount of time available to a HCW by cadre to perform daily tasks in a year, considering authorised and unauthorised absences). Firstly, a desk review of relevant public service statutory policy, rules, and guidelines was conducted to obtain the total number of HCW’s work hours per day, work days per week, and authorised and unauthorised absences allowed within the State’s service. Finally, the Staff AWT was subsequently reviewed and approved by the study’s governance structure. An Expert Group comprising 17 clinical experts were convened to obtain time spent on clinical and non-clinical activities by HCWs in the study’s cadres of interest. These experts were purposefully selected and included individuals who are members of the study’s cadre of interest, currently employed in the public service, and have at least 15 years of experience providing health care services at the primary care level. All experts in the group responded on time that it takes the prioritised health worker cadre to perform the selected activities to acceptable standards, and the mean value of their responses was utilised. The data collected were analysed using MS Excel, consistent with the WISN methodology. Activity standards, clinical and non-clinical workload components, annual service delivery statistics and AWT for the prioritised cadre for each facility were included. To complete the computation, the data collected was defined and analysed as follows: Where in the formula: AWT is the total staff available working time A is the number of possible working days in a year B is the number of days off for public holidays in a year C is the number of days off for official leave in a year D is the number of days off due to sick leave in a year E is the number of days off due to casual leave, study or training leave and maternity leave in a year. Core health activities i = 1,2,3 … n AWi = Annual statistics for each core clinical health service SWi = Standard Workload for each core clinical health service Staff requirement for individual activities: Individual Allowance Standard (IAS), which is the total number of hours per year needed to perform all additional activities undertaken by some HCWs, was also calculated. An Individual Allowance Factor (IAF) identifying the staffing requirement to undertake these workloads was estimated using the: WISN staffing results with fractions were handled as recommended by the WISN guide. 13 WISN differences and ratios were also calculated for each health facility. The WISN difference, which is calculated as the variance between the current staffing norm available by cadre and the computed staffing requirements and identifies staffing gaps or excesses by cadre. The WISN ratio represents the work pressure experienced by the HCW. A WISN ratio of > 1 indicates the availability of more HCWs than required to meet the facility workload.
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