Stage 1: Calculate and compare health workforce productivity at health facilities

Overview

Before you can determine whether there is a productivity problem in a given health facility, you must calculate its health workforce productivity. There are several ways to calculate health workforce productivity, many of which are quite complex. We will focus on a somewhat simpler measure known as total health workforce productivity, which involves calculating the ratio of aggregate service delivery outputs to the use of health workers (inputs). Stage 1 will take you through the steps and necessary data entry to make this calculation.

While you can navigate through the entire toolkit without registering for a user account, in order to save data entered to calculate health workforce productivity (to make later changes or monitor progress), you will first need to register for a user account and log in. Click here to register.

For instructions on creating a worksheet and saving data, click Worksheet Help.

If you have already entered data into one worksheet and want to start a new worksheet, go to My Worksheets and click on the New Worksheet button.

Step 1: List health facilities to compare

In order for the relative health workforce productivity comparisons to be meaningful, the selected health facilities must be comparable. In general, consider comparing facilities that:

  • Are of the same facility type or level of care
  • Offer the same services
  • Have similar staffing structures.

A useful comparison: Comparing all primary health care units within a health district. This comparison is useful because primary health care units generally offer the same package of essential health services.

Not a useful comparison: Comparing a large hospital with a dispensary. Since hospitals serve a very different role than dispensaries and employ different types of health workers, they would likely have different input/output configurations that would be difficult to compare. However, an outpatient department at a hospital could possibly be compared to a dispensary, if the outpatient department offers similar types of services as the dispensary and is staffed with similar types of health workers.

List the facilities to be compared in your productivity assessment, along with their respective catchment populations. To add additional facilities, click the “+ Add Facility” button.

You may want to include all the health facilities within a district, region, province, or even the whole country. You may only want to focus on a certain level of facility across provinces (e.g., district hospitals within the western region of the country). If the needed service statistics and health worker salary data are readily available at the national, regional, or other aggregated level, you may be able to calculate health workforce productivity for as many facilities as you would like. However, if you must travel to individual health facilities to obtain the data, you may need to limit the number of facilities in the productivity comparison due to resource constraints.

Be sure to group each type of facility for comparison as a separate worksheet (e.g., all hospitals in one worksheet and all health centers in another separate worksheet). Once you have entered data for a group of similar facilities for comparison, click the “Save” button. Before proceeding to subsequent steps, we recommend that you name this worksheet (see Worksheet Help for instructions).

District Facility name Facility type Catchment population

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Step 2: Specify data time period

Specify a year-long time period for the service output and salary input data you will use in the productivity calculation.

We use data over a 12-month period rather than a few months or quarters to help account for any seasonal variations that could possibly affect the results.

When you conduct the health workforce productivity analysis for the first time, you will enter the corresponding data points under the section for Time 1.

If you are returning to the data set to enter a subsequent year of data in a new time period (i.e., to monitor progress), then click “+ Add Time Period” to add an additional time period to the data set.

Time {{ $index() + 1 }}

Step 3a: Identify health services for productivity calculation

Consider the health services that are the most essential or represent the majority of the services provided at the level of facility you are assessing. The table below presents examples of the most common health service areas and output indicators used in productivity calculations (Vujicic, Addai, and Bosomprah 2009):

Health service area Output indicator
Outpatient Care # of outpatient consultations
Inpatient care # of inpatient days
Antenatal care (ANC) # of ANC consultations
Labor and delivery # of institutional deliveries
Family planning (FP) # of FP consultations
Child immunizations # of immunizations administered
HIV counseling and testing # of voluntary HIV test results received

List all the health services that will be included in the productivity calculation under the column “Health service area” along with how the output of each service is measured (“Output indicator”) by clicking on the “+ Add Output” button.

Use the standard output indicators that facilities collect in their health management information systems. The number of consultations or services delivered is the most common way to express service outputs, but there are exceptions. For example, the number of inpatient days (rather than the number of inpatients) is the common output measure of inpatient services.

Health service area Output indicator

Please note that only the bottom row can be removed.

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Step 3b: Assign service weights

To calculate total health workforce productivity, the single health service outputs are combined into an aggregate output measure—called an output index—to measure total provision of the selected health services at a facility. Total service provision is not simply the sum of the individual services because not all the services are of equal value in terms of time, effort, and impact. For example, the contribution of one immunization is not the same as the contribution of an assisted delivery. Instead, it is better to assign a weight to each health service.

We recommend using service weights that represent the relative human resources costs of producing the services. While there are specific methods to calculate service weights, these are somewhat complex. We use a set of service weights from the literature as shown in the table below:

Health service area Output indicator Service weight*
Outpatient Care # of outpatient consultations 1.00
Inpatient care # of inpatient days 3.00
Antenatal care (ANC) # of ANC consultations 1.00
Labor and delivery # of institutional deliveries 3.00
Family planning (FP) # of FP consultations 1.00
Child immunizations # of immunizations administered 0.50
HIV counseling and testing # of voluntary HIV test results received 1.00

* Service weights from Vujicic, Addai, and Bosomprah 2009, except for the last health service area, “HIV counseling and testing”

You may use these same values or adjust the weights if they appear unrealistic in your context. For example, in a field test in Laos, because the child immunization strategy at the health center level included an extensive outreach program with health workers exerting much time and effort to reach children in their communities, they assigned a service weight of one (1.00) to child immunizations. However, because the majority of child immunizations at the district hospital are provided to children at the facility (rather than district hospital workers traveling to villages to provide immunizations in the community), they assigned a lower service weight (0.75) for child immunizations at the district hospital level.

If in Step 3a you identified other health services to include in the measurement of health workforce productivity, you should determine which of the above health service areas the additional services are most similar to in terms of time and effort and assign them a corresponding service weight.

In practice, the determination of service weights for use in the productivity calculation will be somewhat arbitrary. While no one would claim that one immunization has the same cost as one inpatient day, we could debate whether 6:1 is the appropriate ratio to compare inpatient days (weight of 3.0) to immunizations (weight of 0.5). Nevertheless, the service weights help us to represent the contribution of each service more accurately than by simply adding all services together.

Enter service weights for each of the health service area outputs listed in the table below.

Health service area Output indicator Service weight
{{ area }} {{ outputIndicator }}

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Step 3c: Enter service output data

For each facility, fill in the output data for each service area with the health facility’s service statistics for the specified 12-month period.

Remember that you must use service statistics from the same time period for all facilities.

{{ name }}

{{ name }}
Health service area Output indicator Time {{ $index() + 1 }} output
{{ area }} {{ outputIndicator }}

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Step 4: Measure health worker inputs

In the first column, list individually all the health workers at the facility who contributed to the provision of one or more of the services you identified in Step 3a (during the same time period you specified in Step 2) by clicking on the “+ Add Health Worker” button.

Where there were multiple individuals within the same cadre, list for example “doctor 1, doctor 2, doctor 3” on separate rows. Include health workers who may have been employed for only a few months during the 12-month period. Also include volunteer health workers—while they may not receive a salary, they are contributing to the service delivery outputs.

For each health worker, enter in the second column an estimate of the person-years (the share of time) each spent providing one or more of the health service areas identified in Step 3a.

For example, a nurse who spent 100% of her time providing one or more of the listed services would be assigned the value of 1.0 person-year. An assistant nurse employed in a 50%, or part-time, position who spent 100% of her working hours on the listed services would also be assigned the value of 1.0 person-year. If a doctor contributed only 80% of her time providing the listed services and spent the remaining 20% of her time performing surgery—which is not among the services listed in Step 3a — she should be recorded as 0.8 person-years. In general, estimating the person-years may be more straightforward in small health facilities where the productivity measure usually includes all primary health services and where all health workers generally provide those services (and thus each would be assigned 1.0 person-year).

In the third column, specify the total compensation received by each health worker during the one-year time period (identified in Step 2). Note the currency you are using in the space above the table.

At a minimum, the compensation should include the gross salary received during the one-year period. If you have information on additional allowances given to the health workers, you may include that as part of the total pay for the time period. For health workers employed for only a few months during the specified time period, enter the total compensation (gross salary only or gross salary plus allowances) they received for those few months. For example, if a pharmacist was hired in the last four months of the selected time period for 1,000 dollars/month (with no additional allowances), enter 4,000 in the compensation column for her. For volunteer health workers, estimate an equivalent compensation they would have received during the time period if they had been salaried staff.

{{ name }}

{{ $parent.name }}: Time {{ $index() + 1 }}
Health workers Person-years Compensation for time period Total HRH costs
{{ hrCosts() | number }}
Total: {{ personYearsTotal() | number }} Total: {{ hrCostsTotal() | number }}

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Step 5: Calculate total health workforce productivity

The table below presents each facility’s total health workforce productivity rate by time period, based on the data you entered in the previous steps. The rate is calculated by dividing the output index by the total HRH costs to obtain the health workforce productivity score. The productivity score is compared to the benchmark and rescaled from 0% to 100%. Recall that the facility with the highest productivity score becomes the benchmark to which all other facilities are compared.

If your country has a predefined productivity benchmark, enter that value in the “Custom Benchmark” cell above the table to recalculate health workforce productivity relative to the predefined standard. Otherwise you will use the rates that appear in the table.

Please note that when you monitor progress in subsequent time periods (see Stage 5), facilities that improve beyond the benchmark facility will have a health workforce productivity rate above 100%.

The third column of the table(s) below lists the output per inhabitant, which is determined by dividing the output index by the catchment population per facility. Like productivity, the output per inhabitant is a relative measure. While the output per inhabitant measure is not used in the calculation of total health workforce productivity, it can be a helpful variable to better understand low productivity. Please take note of the output per inhabitant values, as you will revisit them in Stage 2, Step 3 where you will consider the possible underlying causes of low productivity related to low patient demand. One indicator of low patient demand is a low output per inhabitant. In facilities with low productivity and few outputs per inhabitant, action may be required to increase demand and/or reduce inputs. However, one possible underlying cause for seeing few patients is having a low catchment population. In an effort to ensure access to health services for all, a deliberate decision may have been made to locate a health facility in a sparsely populated area. If this is the reason for low productivity, no further action may be required.

Time {{ $index() + 1 }}

Time {{ $index() + 1 }}
Facility Output index Output per inhabitant Total HRH costs Health workforce productivity score Benchmark Total health workforce productivity rate (%)
{{ name }} {{ timeData()[$parentContext.$index()].outputIndex() | number }} {{ (timeData()[$parentContext.$index()].outputIndex() / parseInt(catchment())).toFixed(6) }} {{ timeData()[$parentContext.$index()].hrCostsTotal() | number }} {{ timeData()[$parentContext.$index()].productivityScore() }} {{ $parent.benchmark($parentContext.$index()) }} {{ Math.round(timeData()[$parentContext.$index()].productivityScore() * 100 / $parent.benchmark($parentContext.$index())) }}%

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Step 6: Review the productivity dashboard

The resulting Health Workforce Productivity Dashboard provides a graphical version of the data presented in Step 5.

Review the Health Workforce Productivity Dashboard to identify the facilities that have a greater need for productivity strengthening efforts.

You will likely see a range of productivity rates, which indicates that some facilities are more productive than the other facilities in the sample. The facilities with a total health workforce productivity rate at the lower end of the scale will appear to have the greatest productivity challenges.

Recall, however, that health workforce productivity is a relative measure and that the facilities are compared to the benchmark—or facility with the highest level of productivity in the sample. The productivity measures indicate where the productivity challenges are largest, but they should not exempt any facility from further scrutiny. As you monitor progress in subsequent years (see Stage 5), you will continue to compare productivity levels to the original benchmark established by the most productive facility (or the custom benchmark, if available) in the first time period.

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Step 7: Select facilities for qualitative assessment

Determine which facilities to include in the qualitative assessment phase.

Now that you know the health workforce productivity of each health facility in your sample, you need to determine if you will involve all or only some of the facilities in the subsequent stages of the productivity assessment process. The qualitative assessment will allow you to conduct further investigations into the facilities’ productivity levels. Because the qualitative assessment processes described in Stage 3 require logistical, human, and other resources, you likely will be limited in how many facilities you will be able to include in the fieldwork phase.

We recommend that you include all facilities where improved health workforce productivity is a high priority. Usually this means the facilities with the lowest levels of productivity. In addition, we suggest you include a few high-productivity facilities to learn which of their approaches may be resulting in higher levels of productivity. Remember that there may be substantial potential for productivity improvement even in the most productive facilities.

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