Table 2 A summary of the WISN implementation and staffing norms development process in Ghana

1

Governance and technical processes

Following a capacity building workshop facilitated by WHO, a National Steering Committee (NSC) was established to provide political and technical leadership for the application of WISN for the purpose of developing staffing norms in Ghana. The NSC also led in mobilising funding for the process. A 17-member Technical Working Group (TWG), drawn from various agencies was also constituted to undertake the WISN application. The TWG routinely reported the progress of work to the NSC and received guidance as and  needed. In each health facility that was visited, an Expert Group was formed by occupational category to assist in the setting of activity standards

2

Determining the priorities for WISN application

Based on the policy direction of the Ministry of Health, it was prioritised to apply WISN for all health workers in the country (across 141 categories of clinical and non-clinical staff). In a first phase from 2013 to 2014, 70% of the categories prioritised were covered while the rest were covered in a second phase in 2017–2018

3

Estimating available working time (AWT) for health professionals

In determining the AWT, national leave policy which stipulates the number of days each category of health workers was entitled to was used, alongside, the average number of sick leave taken by health workers which was obtained from each of the health facilities visited, national public holidays, average maternity leave and training days per year were deducted from the total annual working days

4

Defining the workload components

The workload components were defined as the tasks (duties) performed by staff on a typical day. These workload components were classified into three: Health Service Activities (or Administrative Activities in case of administration staff), Support activities and Additional activities

    Health Service Activities refer to tasks performed by all members of a staff category for which regular statistics are collected. Example, number of deliveries, OPD, surgeries etc

    Support activities are tasks performed by all members of a staff category, but statistics are not collected regularly. Example, documentation of patient care, meetings, etc.

    Additional activities are tasks performed by some (not all) members of a staff category, but statistics are not collected regularly. Example, administrative duties

Data was collected from 54 randomly selected health facilities and institutions to develop the workload components and activity standards which was validated and applied in a nationally representative sample of 138 health facilities countrywide across all levels of the public health system. Expert Groups were formed at the health facilities visited who provided technical insights into their work determine the workload components using a purposely deigned job components tool

5

Setting activity standards

Activity Standard (or Service Standard) is the time it takes a trained and well-motivated member of a particular staff category to perform his/her duties to acceptable professional standards in the circumstances of the country/facility. Setting of the activity standards was undertaken concurrently with that of the workload components. Aimed to achieve a technical consensus, the Expert Group in the first health facility provided a list of health service activities they perform, and the corresponding time spent on each. These were then collected and sent to the next health facility, where the completed tool was given to another batch of health professionals (in the same category) to indicate if they agreed with the previous batch of health professionals' proposal. The process continued until a near consensus was achieved where no new workload components were added and the standard time acceptable to all. Where there were still divergent views, non-obtrusive direct observation to determine the standard time was carried out. In all the 192 health facilities used (54 pilot sites for workload components and activity standards development and 136 scale-up application), the institutional staffing requirement was calculated and discussed with the health workers and their management whose comments were used to refine the analysis

6

Establishing standard workloads

Standard Workload is the amount of work (within one activity) that one person could do in a year. Standard Workload is the Available working time divided by the activity standard (Service Standard) of a particular task

(Standard Workload = AWT ÷ Activity Standard)

Standard workload for all activities and categories of staff were determined with the aid of the WISN software

7

Calculating allowance factors

Allowance factor (AF) is the estimation of the number of health workers required to cover support activities and additional activities. There are two types of allowance factors—category and individual

The category allowance factor (CAF) is a multiplier that is used to calculate the total number of health workers, required for both health service and support activities

The individual allowance factor (IAF) is the staff required to cover additional activities of certain cadre members

These calculations have been automated in the WISN software

8

Determination of staff requirements

In determining the staff requirements, in each health facility, the annual workload statistics was obtained from the annual report, health information system and admission and discharge books in the wards, as appropriate. For each workload component, the annual service statistics was used to divide by its respective standard workload. A sum of all workload components was then put together to get the total staff requirement for all health service activities. The allowance factors are then applied to get the true staffing requirement using the formula below

Total required number of staff = (A×B) + C,

where

A = required staff for health service activities

B = category allowance factor

C = individual allowance factor

The staffing requirements for the individual staff categories and health facilities/institution was computed using the stated formula using the WISN software

9

Development of national staffing norms from the WISN analyses

The facility-level WISN results (staffing requirements) were validated and meta-analysed to establish a national staffing norm for the various categories of health facilities. This process included data preparation and validation, statistical analysis for setting staffing norms and validation

(a) Data preparation facility-based WISN results were compiled in an excel template for inspection and comparison by facility and staff category. Each facility WISN output (staffing requirement) was assessed for internal and external validity. For internal validation, the facility WISN output was checked to see if the results generally made sense in the light of expert knowledge about the general staffing situation in that facility; and for relativities among cadres in the facility—for example the ratio of doctors to nurses from the WISN results. For external validation, each facility WISN output was assessed to find out if there is any significant difference between that facility and others of similar status and service utilisation. Health facilities were then grouped into workload categories. Whenever unexplained discrepancies were detected, a verification of the inputted data vis-à-vis expert consultation and a re-run of the WISN study was made to correct the errors (if any)

(b) Determining the national staffing norms from WISN results: The facility based WISN results (grouped by type of health facility and similarity of workload) was meta-analysed using random effect model of meta-analysis (the random effect model assumes that when pooling results, there could have been variations within and across studies). The pooled average staffing requirements for each cadre based on the meta-analysis and its boundaries of uncertainties (95% confidence limits) were considered the ‘statistical limits’ for setting the staffing norms:

   The lower limit of the 95% confidence interval of the pooled mean requirement of each category of the staff was considered the minimum staffing limit on the staffing norm for that cadre

   The upper limit of the 95% confidence interval of the pooled mean requirement of each category of the staff was considered the maximum staffing limit on the staffing norm

(c) Validation and adoption The draft staffing norm was then reviewed and validated in a series of consultation and validation workshops across the country with stakeholders across all levels of the health system including health professions regulators, labour unions, and frontline health managers. Feedback from the series of validation workshop was used to finalise the staffing norms document before it was adopted as a national policy for health workforce planning, distribution and management in the public health sector