THE REPUBLIC OF UGANDA

GUIDELINES FOR IMPLEMENTATION OF

WORKLOAD INDICATORS OF STAFFING NEED

(WISN)

METHODOLOGY IN UGANDA

MINISTRY OF HEALTH

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UGANDA

MINISTRY OF HEALTH

GUIDELINES FOR IMPLEMENTATION OFWORKLOAD INDICATORS OF STAFFING NEED

(WISN) METHODOLOGY IN UGANDA

MARCH 2019

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Contents

Abbreviations and Acronyms.......................................................................................................................3

Foreword ...........................................................................................................................................................4

Acknowledgements ........................................................................................................................................51.0 Introduction ...............................................................................................................................................6

1.1 General objectives of the Guideline ................................................................................................61.2 Specific Objectives of the guideline ................................................................................................61.3 Scope of the Guidelines .....................................................................................................................61.4 What is WISN ........................................................................................................................................71.5. Rationale for WISN application .......................................................................................................71.6. How to use WISN ...............................................................................................................................81.7 Functions of WISN ...............................................................................................................................81.8 Application of WISN Results ..............................................................................................................8

2.0 WISN technical procedures ...................................................................................................................92.1 Mobilizing Commitment to WISN ................................................................................................ 102.2 Determining the objectives and focus of the WISN process ................................................. 102.3 Designing the implementation strategy ...................................................................................... 102.4. Developing an operational plan and budget ........................................................................... 102.5 Setting up the Implementation Teams and Task Forces .......................................................... 122.6. Orienting and training the implementation groups ................................................................ 132.7. Collecting and analysing the data ............................................................................................... 132.8. Sharing WISN results ....................................................................................................................... 132.9 Integrating WISN into management systems ............................................................................ 13

3.0 WISN Activities Step-by-Step process ............................................................................................. 143.1. Step 1: Determine Priority Cadres ............................................................................................... 143.2 Step 2: Enter Data into WISN data Extraction Tool .................................................................. 143.3 Step 3: Analyse the data ................................................................................................................. 15

4.0 Presentation and Interpretation of WISN Results.......................................................................... 154.1. Health facility results by cadre ...................................................................................................... 174.2 District aggregate results by health facility per cadre .............................................................. 18

5.0 Institutional Arrangement and implementation Framework ...................................................... 195.1 Other Key Players...............................................................................................................................21

5.1.1 District or Municipality Health Officers/Heads of health facilities.................................. 215.1.2 HMIS Focal person .................................................................................................................... 225.1.3 Institutional Head of Human Resource ................................................................................ 22

6.0 Monitoring and Evaluation of Implementation of WISN guidelines ......................................... 22Data Quality Management .................................................................................................................... 23

Additional References..............................................................................................................................24Appendix 1: Template 1: Monthly HMIS 105/108 reports ................................................................. 25

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Abbreviations and Acronyms

CAO Chief Administrative OfficerDHO District Health OfficerDHMT District Health Management teamDSC District Service CommissionHMIS Health Management Information SystemHRH Human Resources for HealthHSD Health Sub-DistrictHSDP Health Sector Development PlanHPCs Health Professional CouncilsIPs Implementing PartnersJDs Job DescriptionsKCCA Kampala Capital City AuthorityLGs Local GovernmentM&E Monitoring and EvaluationMOH Ministry of HealthMOLG Ministry of Local GovernmentMOPS Ministry of Public ServicePHRO Principal Human Resource OfficersUCMB Uganda Catholic Medical BureauUMMB Uganda Muslim Medical BureauUPMB Uganda Protestant Medical BureauUSAID United States Agency for International DevelopmentWHO World Health OrganizationWISN Workload Indicators of Staffing Need

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Foreword

The Workload Indicators of Staffing Need (WISN) methodology was developed by the World Health Organization in 1998. It is a scientifically proven analytical tool for efficiently planning and managing human resources for health. Several countries have adopted it for use in determining their health staffing needs.

Uganda faces significant human resources challenges in the health sector, primarily characterized by under-staffing and high absenteeism among existing staff. In 2006, Uganda adopted the WISN methodology to enable the available health staff to be appropriately and equitably deployed so that they can be more productive and responsive to the populations’ health needs. Although the tool is an essential component for the efficient utilization of the existing health workforce, there were no customized guidelines available to adapt the WISN implementation to the Ugandan context.

To address this gap, the Ministry of Health with technical guidance from Ministry of Public Service and the USAID-funded Strengthening Human Resource Health Activity implemented by IntraHealth International developed this guideline for users to enable them to implement the WISN methodology in Uganda.

This guide gives users the information and guidance they need to apply the WISN methodology to determine the number and category of health workers they need to handle the workload in a health institution, facility, department or unit. This information can help health managers to plan the most efficient utilization of existing staff and plan for recruiting any additional staff.

Special thanks go to the Ministries of Public service and Local Government, IntraHealth International, and all the officers who gave their time and expertise to have this guideline developed. It is my hope that this tool is embraced by users at all levels in the sector for efficient and effective utilization of human resources for health to deliver better quality health services.

Dr. Diana Atwine PERMANENT SECRETARY

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Acknowledgements

The Ministry of Health is sincerely grateful to the United Stated Agency for International development (USAID) through the Strengthening Human Resources for Health (SHRH) Activity implemented by IntraHealth International for supporting the development of this customized WISN guideline. The MOH is equally very grateful for the support, cooperation and collaboration rendered by Ministry of Public Service, Ministry of Local Government, Dr Vincent Oketcho the chief of party COP IntraHealth Dr, Haruna Lule, Senior Advisor HRM, and entire IntraHealth Strengthening Human Resources for Health (SHRH) staff, Professor John Okiria (Lecturer- International Health Sciences University, Kampala)’ the MOH technical team headed by Commissioner HRM and all other stakeholders who participated in one way or the other in this process for the unwavering technical guidance and support during the process of developing this guideline.

May the almighty God reward everybody abundantly.

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1.0 Introduction

The Ministry of Health (MOH) has a vision for Uganda to have an adequate, appropriately skilled and equitably distributed health care workforce that is responsive to the needs of the people. However, Uganda, like many other countries, continues to experience a shortage of qualified health workers with inequitable geographical distribution and inappropriate skills mix. The workload in health facilities has also increased as the population has grown, and people have become more aware of services offered and have increased their demand for services. Now more than ever there is a need to most efficiently and effectively use the scarce human resources for health available.

Countries use different criteria to determine the appropriate staffing levels for health facilities, and it remains a key challenge globally. Usually these decisions are made as a matter of custom and practice considering as much as possible population growth, budget allocations and constraints, anticipated turnover, needed skills, changes in technology and in disease burden. Uganda currently recruits and deploys staff using fixed staffing norms based on the facility size which is tied to bed capacity rather than workload. These fixed staffing norms are inherently inefficient as there is a mismatch between facility workload and health worker allocation – facilities with low workload underutilize staff and facilities with high workload overburden their staff.

This guide presents the Workload Indictors of Staffing Need (WISN) methodology as an analytic planning and management tool for the management of human resources for health in Uganda.

1.1 General objectives of the Guideline

The main objective of this guideline is to introduce the users to the WISN methodology and guide them in its use while determining the numbers and category of health workers needed in a given health institution, facility, department or unit to adequately handle the workload.1.2 Specific Objectives of the guidelineThe specific objectives of the guidelines are to:

• Raise user awareness on the WISN methodology

• Equip users with knowledge to be able to use the WISN methodology

• Outline the institutional arrangement involved in managing and implementing the WISN methodology

• Describe the roles of key players in WISN management and implementation

1.3 Scope of the Guidelines

These guidelines shall apply to government health facilities in Uganda which include but are not limited to:

• National Referral Hospitals (NRHs)

• Regional Referral Hospitals (RRHs)

• General Hospitals (GHs)

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• Health Centre IVs (HCIVs)

• Health Centre IIIs (HCIIIs)

• Health Centre IIs (HCIIs)

• Uganda Blood Transfusion Service (UBTS)

• Uganda Cancer Institute (UCI)

• Uganda Heart Institute (UHI)

• Uganda Virus Research Institute (UVRI)

The users should refer to these guidelines to determine the numbers and category of health workers needed in a given facility based on workload. The guideline will be reviewed by the MOH if the need arises.

1.4 What is WISN

The Workload Indicators of Staffing Need (WISN) methodology is an analytical, planning and management tool developed by WHO in 1998 and field tested in Tanzania, Kenya, Sudan, Papua New Guinea, and Sri Lanka among others. It was successfully implemented in Turkey and Bangladesh. Many other countries, most recently Indonesia and Mozambique, have since applied it to study and improve the performance of their local systems. In Uganda, WISN was first piloted in 2006 and some capacity has been built in the application of the WISN methodology since then. Uganda has approximately 50 trained WISN resource persons from various organizations including KCCA, UCMB, UPMB, MOH, Local Governments (LGs) and Uganda Martyrs University-Nkozi (UMU). WISN application has been taking place in selected institutions and districts, mainly with the support of implementing partners (IPs) and without customized WISN guidelines from the line Ministries on its use in Uganda. This rendered many health managers especially in districts unable to use the methodology to determine their staffing needs and deployment without such official guidance. It is anticipated that this guideline therefore will fix this problem.

1.5. Rationale for WISN application

The main purpose of WISN methodology is to have equitable distribution of human resources for health where they can be efficiently and effectively utilized. Specifically, the WISN methodology can be used to:

• Determine how many health workers of a particular cadre are required to cope with workload of a given health facility

• Assess the workload pressure of the health workers in that facility or unit

• Identify the underutilized staff in a given department who can be redeployed in another heavy workload pressure where applicable

In line with Public Service Reforms (e.g. restructuring of the civil service, decentralisation, e.t.c) and in order to achieve the Health Sector Development Plan (2015/16-19/20) goal of accelerating movement towards universal health coverage with essential health and related services needed for promotion of a healthy and productive life, the WISN methodology seeks to supplement the existing staffing norms that are based on population level and facility size. The current standard staffing norms have been overtaken by events such as rapid population

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growth, increased demand for services, change in disease management policies, increased disease burden and pattern, new cadres and task shifting/sharing and changes in technology. WISN therefore specifically seeks to:

• Re-align the staffing of health facilities with health sector human resource demands and requirements in Uganda

• Address the shift and effects of the changing health sector needs which demand for new approaches in determining staff size and capacity for effective service delivery

• Guide the health sector and health managers on equitable and cost-effective allocation of health workers in health facilities for improved service delivery

• Promote equitable staffing of health facilities based on workload

• Promote efficiency by maximising human resource utilisation in health facilities and

• Minimise wastage by reducing redundancy of excess staff in health facilities

1.6. How to use WISN

WISN is a tool which applies scientific approach to determine staffing needs. The WISN methodology is applied through steps to calculate, analyse and interpret results to determine the required staff numbers, levels and categories based on workload. Managers and users shall be provided with a WISN technical user guide and a manual which contains all the necessary steps applied in calculation, analysis and interpretation of WISN results.

The WISN results can be used to improve the staffing situation, allocate new functions and transfer existing functions to different categories of health workers and plan future staffing of health facilities.

1.7 Functions of WISN

The functions of WISN include the following; • Determine staff structures for health facilities - this will be necessary during the review

and establishment of staffing levels for new and existing health facilities

• Facilitate succession and recruitment planning

• Provide the data necessary for health managers to determine the allocation and redeployment of staff across health institutions, facilities and departments

• Promote efficient utilization of the existing health workforce by distributing health workers in facilities and institutions based on workload.

• Facilitate institutions to manage performance

1.8 Application of WISN Results

The WISN results for staff changes within health Institutions and facilities shall be approved by the respective responsible officers including permanent secretaries (MOH, MOPS and MOLG), executive directors, hospital directors, chief administrative officers, and town clerks. Such changes include: endorsement of staff allocations, recruitment, placements and re-deployments.

WISN results that require staffing above recommended norms for the facility shall be approved by the MOPS (on a case by case basis) in collaboration with line Ministries following the existing review and restructuring guidelines issued by MOPS in 2016.

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2.0 WISN technical procedures

This section outlines the steps of the WISN process and is intended to guide users on its application. Managers should review and adapt the steps as necessary to their particular situations. The steps are presented in sequence but in practice some may take place concurrently rather than sequentially (Figure 1).

Step 1: Situation Analysis and Decision to Use WISNThe first step is to conduct a situation analysis. This is usually triggered by reports from the community that services at a facility are unsatisfactory, or by complaints from staff that their workload is too high to manage. At this point, the situation analysis may suggest that WISN should be used to address the challenges faced. Once it is decided to use WISN, the focus area should be determined (e.g. maternity ward, OPD, etc.). The WISN team should therefore be identified and oriented to the data collection tools mobilized.

Step 2: Data Collection and AnalysisData collection and analysis involves reaching a consensus on what data to collect regarding which priority cadres. Data is then collected and entered into WISN data extraction tools and then entered into the WISN analysis tool. The data must be validated for accuracy and completeness.

Step 3: Present and Interpret Results for Decision MakingThe results must be interpreted and presented for decision making. Once decisions have been made, managers must monitor for changes in the productivity and motivation of staff, as well as the quality of services. That monitoring information feeds into subsequent situation analyses to follow the process again in the future to ensure continuous and sustained improvements in service delivery. Figure 1: WISN Process Summary.

Take action basing on results (Work pressure)Monitor Change in

Productivity Motivation.....

• Construct 7 by 6 results summary tables.• Extract the LG staffing norm from the Public Service Staffing requirement by

cadre• Extract the actual staffing levels by cadreform the current facility establishment• Enter the WISN results in the table and then calculate the difference [E] of the

shortage or surplus• Determine the ratio [F] =[Current staffing level to WISN requirement]• Calculate the work pressure[1-Ratio]=100

Present &Interpretresults

Data collection& analysisa

Decision-WhyWISN?

• Decide and communicate wich data to collect• Ensure data completeness• Determine priority cadres• Collect and enter data into WISN data extraction tool[HMIS

105/108] and finally enter data into WISN analysis tool

• Determinesituation, objectives &• area of focus• Design implementationstrategy and• operational plan• Identify and orient WISN team• Mobilize resources and data collection tools

HRHSituationAnalysis

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2.1 Mobilizing Commitment to WISNThe success of the WISN effort is dependent on the level of commitment of the key stake holders including political leaders. Before the work starts, it is vital to ensure that these senior officials understand what the WISN methodology is, what results it will produce, and how the results can help their decision-making. A sensitization meeting to inform these stakeholders and answer their questions can help increase their commitment to the process.

Other groups are also very important to WISN success. These are the professional bodies of health workers (such as medical, allied health and nursing associations/councils) and trade unions. You should seek to share with these groups what the WISN method is and how the results will be used. The goal is to gain the commitment of these groups or, at the very least, avert their active opposition.

2.2 Determining the objectives and focus of the WISN process

You must define clearly why you want to use the WISN methodology and for what decisions. In the district health system for example, it would help the DHOs to:

• Identify and justify staffing needs by category

• Inform the process of staff transfers

• Determine the number of health workers required

• Help in deciding where new staff recruited in the district are to be posted

• Ensure efficient use of the scarce human resources and improve quality of services

In general, these are some of the critical issues that necessitate the use of WISN. This is applicable within the health facility and the district as a whole. It can be done for only one cadre or selected cadres provided their activity standards and allowance factors have been established (NB. These are already provided for some cadres).

2.3 Designing the implementation strategy

It is preferable to start small, for example by developing WISN initially for only one staff category working in one type of health facility. The advantage of this approach is that it allows the involved officials to develop experience in the WISN methodology. It also helps ensure that the way in which WISN is implemented is feasible. The next WISN process can then have a wider scope, after experience is accumulated and the results are used for decision-making.

Developing WISN simultaneously for several cadres in the same type of health facility is an example of a wider WISN scope. It has many advantages over a focus on only a single staff category. It provides an excellent opportunity to examine the total workload of the facility (or at least a major part of it), not only the work of one cadre in isolation. Often different cadres perform the same duties.

2.4. Developing an operational plan and budget

The WISN implementation strategy must be translated into an operational plan and budget. The prompting questions below are intended to help users in developing their own plan. The list is not exhaustive. Additional considerations may be important considering the users’ own setting.

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Issue Prompting Questions

2.4.1 Defining strategy

• Shall you do a pilot study first, or can you move right away to a complete WISN implementation?

• Is a special field study necessary to verify initial WISN results? If yes, where should it be done and by whom?

• The users must develop a budget and timetable for undertaking all the activities. The timetable should be long enough to allow the work to be completed well

2.4.2 Implementing Strategy

• What will be the composition of the group that will guide the overall WISN process?

• Who will manage the day-to-day flow of activities in implementing WISN?

• How shall we obtain well-informed advice regarding the work content of the staff categories in your WISN study?

• How frequently, when and where will the teams of implementers and work-content resource persons meet to do their work?

• The user must think through what resources you need to execute your operational plan. Which members of your own staff or staff from other relevant institutions or organizations should be assigned to the work, either full-time or part-time?

2.4.3 Orienting and training

• When, where and how will the group in charge of the overall WISN process be oriented to WISN?

• How will the implementers and work-content experts be trained in WISN?

• Who will do the training? • What format will it take?

2.4.4 Collecting and analyzing data

• How will the necessary data on staffing and workload be collected?

• Will all data collection and analysis take place at the same time, or will it be staggered?

• Should the calculations be done manually or by computer? • Who will analyze and interpret the WISN results? When will

this take place and where?

2.4.5 Sharing results and integrating WISN

• When, where and how will the WISN results be shared, and with whom?

• How will the WISN method be integrated into the management and budget systems in the long term?

• If there is need for additional advice, either for launching the WISN process or for data collection and analysis, contact the WISN resource persons

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NOTE: Consider carefully the advantages and disadvantages of using a computer to process the WISN data. In a small scale WISN study, the amount of data is relatively small and therefore a manual approach may suffice. In a big scale WISN, a considerable amount of data must be processed quickly and accurately. In this case, computerizing the WISN data analysis is important. The WISN software accompanying the user manual was designed with such big WISN applications in mind. Computerization can also be helpful in more limited WISN applications, when WISN becomes an integral part of management systems.

2.5 Setting up the Implementation Teams and Task Force

Successful implementation of the WISN process requires two different sets of individuals.

The first is the WISN technical task force. The technical task force works with the second set of individuals: an expert/resource working group (or groups). The expert working group, can involve other key individuals later, as needed.

The technical task force/team shall be responsible for implementing the WISN process. The composition of that team varies depending on the implementation level as outlined below.

Central Government Level

At the central government level, the WISN Technical Team shall comprise of Technical Officers nominated from the following Ministries:

• Ministry of Health

• Ministry of Public Service

• Ministry of Local Government

• Ministry of Finance, Planning and Economic Development

• Health Service Commission

• Any other relevant MDA

District, Municipal or Town Council Level

At these levels, the WISN Technical Team shall comprise of:

• CAO/Town Clerk

• The DHO/Municipal Health Officer

• Planner

• The head of human resources

• Heads of Health Sub District

• Biostatistician/HMIS focal person

• The committee may co-opt any other technical persons for the effective implementation of the WISN activities

Health Facility Level

At Health facility Level, the WISN Team shall comprise of:

• Head of Health facility e.g. Hospital Director, Medical Superintendent e.t.c

• Head of Nursing

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• Heads of Department

• Human Resource Officer

• Biostatistician/ HMIS focal person

• The Committee may co-opt any other Technical Persons for the effective implementation of the WISN activities

NOTE:1. The District WISN Team will be directly responsible for the Lower Level WISN activities

2. The WISN Team shall meet bi- annually

3. The reports of the WISN technical team will be submitted to the inter- ministerial technical team after every six months

2.6. Orienting and training the implementation groups

The Technical task force must be oriented on the WISN methodology before starting its work. It does not need to understand the technical details of each methodological step. It must, however, have a good understanding of the basis for calculating the required number of staff and why basing this calculation on the workload is a great improvement over the earlier method. Sharing results from prior small-scale WISN studies, if available, can be a great help in this regard.

A training should be organized to orient the key stakeholders in the WISN methodology. The members of the technical task force should be trained in each WISN step in a three-day training using real data from facilities they are familiar with.

2.7. Collecting and analysing the data

The WISN methodology is based on routinely collected data on the workload of health workers. The information is obtained from the HMIS 105 and HMIS 108 reports. This may include data from the previous calendar year on in-patient admissions, outpatient visits, deliveries, surgical operations or laboratory tests, among others. The collected data shall be analyzed using the customized WISN tool in accordance with the methodology under Section 3.0 of these guidelines.

2.8. Sharing WISN results

After data analysis, the WISN results shall be shared with the institution or facility’s stakeholders on an annual or bi-annual basis or as needed. The stakeholders may include the inter-ministerial technical team, the district WISN technical team, facility WISN technical team, development partners, and the health workers. The bi-annual reports shall be shared with the district WISN technical team and facility level technical team and copied to the inter-ministerial WISN team. The annual reports are to be shared with the inter-ministerial WISN team and development partners where appropriate.

2.9 Integrating WISN into management systems

Application of WISN should not be a stand-alone or a one-off exercise. The ultimate goal is to incorporate its application into the annual cycle of planning and budgeting for the institution or facility. The WISN technical teams shall therefore hold regular WISN meetings to discuss results and implement the resolutions of WISN outcomes. The management shall also make available the required budget and inputs for effective implementation of WISN activities.

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3.0 WISN Activities Step-by-Step process

The WISN methodology establishes workload in a facility for a specific period using the data reported in the monthly HMIS 105/108 reports. It is important that the data is complete and accurate. Annual outputs/workload for the period of study are required.

Table 1: Data CompletenessHealth Unit Level of

careMonthly reports Annual

HMIS 105 HMIS 108

Total Data obtained

% data obtained

Nadiya General hospital Hospital 12 12 24 100Kakindu Health Centre IV 12 12 24 100Kayenje Health Centre III 12 12 24 100Mutungo Health Centre III 12 12 24 100Mugoyo Health Centre III 10 12 22 92

Where it may not be possible to have all the monthly reports as in Table 1 above, Mugoyo Health Centre had only 10 months of the HMIS 105 reports for the year of study. Calculate the average monthly workload of the 10 months and use that as the workload for each of the missing months. Remember the less the actual data available the less accurate your findings will be - so make sure you have at least 75% of the actual data requirements.

3.1. Step 1: Determine Priority Cadres

WISN methodology can be used to determine the actual staffing needs for any cadre provided their activity standards and allowance factors have been established. Selected critical cadres’ activity standards and allowance factors have been configured /entered into the WISN tool. This is how you gather the data needed for the tool:

1. Obtain the staffing norms of each cadre as per the Public Service staffing norms by level of care (for example, there should be seven clinical officers in a general hospital).

2. Obtain the current staffing/actual number of employees of a cadre in service, year under review in a particular facility. (See example in Table 2).

Table 2: Example of cadres, staffing norm, & current staffing level (Nadiya GH)Staff cadre LG Norm Current staffing

Clinical Officers (All ranks) 7 7

All Midwives 28 28

All Nurses 73 40

Laboratory staff 4 2Medical Officer (All ranks for GH) 12 1

3.2 Step 2: Enter Data into WISN data Extraction Tool

See Appendix 1 for a customized spreadsheet for capturing data in the format and structure that is in alignment with the HMIS 105/108 forms. Alternatively, you can develop one if you do not have a soft copy of the HMIS108/105. Follow these steps:

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1. Extract the required outputs/workload data (see Appendix 1)

2. Enter workload data into the WISN analysis tool

3. Enter the name of the facility, level of care, sub district, district and number of wards

4. Transfer the annual totals from the data collection sheet to the WISN data entry tool correspondingly.

5. Enter the current staffing levels of the facility per cadre into the WISN analysis tool

Note: All the activity standards and allowance factors have been built in the tool and your role is to input the workload as required in the WISN tool.

3.3 Step 3: Analyse the data

The tool will analyze the data but one has to ensure that annual outputs are entered correctly. The tool does this by converting the workload to human beings equivalent of each cadre. The WISN results may have fractions of human beings. The following rounding off rule should be used.

Table 3: Rounding off WISN results rule

WISN result Rounding off rule WISN result Rounding off rule

Less than1.0 -1.1 Round down to 1 person >1.1-1.9 Round up to 2 persons

2.0-2.2 Round down to 2 persons >2.2-2.9 Round up to 3 persons

3.0-3.3 Round down to 3 persons >3.3-3.9 Round up to 4 persons

4.0-4.4 Round down to 4 persons >4.4-4.9 Round up to 5 persons

5.0-5.5 Round down to 5 persons >5.5-5.9 Round up to 6 persons

Note: Keep the result to ONLY one decimal place before rounding up. Follow the rule for all the WISN results consistently for comparability. From 5 up wards you round off normally.

4.0 Presentation and Interpretation of WISN Results

Summary tables should be constructed in order to make WISN results meaningful and usable for management and decision-making. Tables can be made by cadre in each facility (Table 5), cadre across district (Table 6), facility across district for each cadre (Table 7).

The WISN results are analyzed in two ways:1) Difference between current staffing and required number of staffs according to

WISN. You can use this to identify the health facilities that are relatively understaffed or overstaffed.

2) The WISN ratio or the ratio of current staffing to required staffing – this is a proxy for work pressure in a health facility. If you divide the current staff by the required number and the result is 1 it means that the current staffing in the facility is in balance with the workload experienced at that facility. A WISN ratio of less than one indicates that the current staffing is not enough to cope with the workload in the facility. A WISN ratio of greater than 1 indicates that the facility is overstaffed in relation to workload. The smaller the WISN ratio, the greater the work pressure and the more need there is for managers to try to do something to remedy the situation.

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Table 4 expands the analysis of these results and some possible actions that can be made based on them.

Table 4 General interpretations and suggested actions for decision making

Analysis result Interpretation Implications in terms of work pressure

Suggested action to be taken

A negative difference:

Current staffing – WISN Requirement = negative number

- and/or -

WISN Ratio Less than 1: (Current staffing/WISN requirement) = less than 1

- and/or-

High work pressure:

(1 – WISN ratio) *100% = high and is a positive number

There is a deficit in the staffing according to WISN

High workload pressure exerted on the existing staff.

Transfer in more staff of the cadre from facilities/unit/department that may have surplus. If there is no transferable staff, recruitment should be done

A positive difference:

Current staffing – WISN Requirement = positive number

- and/or -

WISN Ratio Greater Than 1: (Current staffing/WISN requirement) = greater than 1

- and/or-

Low work pressure:

(1 – WISN ratio) *100% = negative number high and is a positive number

There is a surplus/more than enough of the cadre

Ideally there should not be any work pressure among the cadre instead they should be less occupied at work and so complaints about workload should not be tolerated

Transfer out the surplus to the facilities that have deficit of that cadre. Investigate the probable causes of the workload which is usually a factor of low utilization.

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Analysis result Interpretation Implications in terms of work pressure

Suggested action to be taken

No Difference:

Current staffing – WISN requirement = zero

-and/or-

WISN ratio equals 1:

(Current staffing/WISN requirement) =1

-and/or-

Work pressure =0%: (1-WISN ratio)*100%=0

Staff sufficient for the workload

This means that the existing workload matches the available staff. So services delivery in terms of workload should not be an issue

Maintain and ensure that there is quality

(WISN ratio X 100)= Current staffing level using WISN)

This reflects the actual current percentage staffing level according to the work load.

The lower percentage, the higher the work pressure. A 100% means no work pressure, meaning the current number of staff is enough for the workload

Use this for advocacy and justification of the staffing requirements. As this is the actual that is scientifically determined.

Note: 1. The higher the WISN difference, the lower the Ratio and therefore the higher the work pressure

2. Where there is need for additional staff, authority to recruit shall be sought from MOPS in line with public service procedures.

4.1. Health facility results by cadre

Construct a table as shown in Table 5 and populate each column as below:

• Column A: Fill in the cadre of interest

• Column B: Fill in the staffing norms for each cadre according to the approved government staffing structure

• Column C: Fill in the actual staffing levels (staff in post) by cadre

• Column D: Enter the WISN results by Cadre

• Column E: Calculate the difference between the actual staffing (Column C) and the WISN calculation (Column D). This gives you the shortage or surplus of staff according to workload.

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• Column F: Calculate the ratio (Current Staffing Level to WISN requirement)

• Column G: Calculate the work pressure with this equation: (1-F)*100% = Work Pressure

Table 5: Namanve Hospital Summary

A B C D E F G

Staff cadre (A) LG Norm (B)Current staffing

(C)WISN (D) DIFF(C-D) =E RATIO (C/D) =F

Work Pressure(1-F)*100

Clinical Officers 7 7 8 -1 0.9 10%

Midwives 28 28 15 +13 1.9 -90%

Nurses 73 40 26 +14 1.5 -50%Doctors 12 3 10 -7 0.3 70%

Table 5 shows that according to WISN, only 15 Midwives are required for the existing workload and yet the current staffing level for Midwives is at 28. Whereas this is in line with the Local Government (LG) staffing norm, in terms of workload, this is excess by 13 staffs. LG Government Norm provides for 73 Nurses as a staffing norm, only 26 are actually required.

4.2 District aggregate results by health facility per cadre

The results from multiple health units in the district can be aggregated to determine the total district requirement per cadre (Table 6) and by facility per cadre (Table 7).

Table 6: A Sample District summary per the selected cadres

Cadre (A)LG Staffing Norms (B)

Current Staffing Level(C)

WISN norm (D)

Difference (C-D)

WISN Ratio (C/D)=F

Work pressure (1-F)*100%

Doctors 16 3 16 -13 0.2 80%Clinical Officers 33 27 36 -9 0.8 20%

Nurses 128 51 83 -32 0.6 40%Midwives 56 63 63 0 1.0 0%

Table 5 shows that the doctors have the highest work pressure with a total deficit of 13 doctors for the available workload in the district.

Note: The higher the work pressure percentage the more the work pressure is being experienced by that cadre. Work pressure of 10% and below is considered tolerable hence normal. WISN Ratio percentage reflects the current actual staffing level as per the current work load.

Table 7: A Sample District Summary per Facility for Nurses

Health CentreLevel of Care

(A)LG Staffing Norm (B)

Current Staffing(C)

WISN Norm (D)

Difference (C-D)

WISN RATIO (C/D)=F

Work Pressure %

(1-F)*100%

Nadiya HOSPITAL 73 40 26 14 1.5 -50%Kakindu HC IV 8 2 6 -4 0.3 67%Mugoyo HC III 7 2 9 -7 0.2 78%Kayenje HC III 4 0 5 -5 0.0 100%Kabuye HC III 4 1 4 -3 0.3 75%Mutungo HC III 4 0 6 -6 0.0 100%Majje HC III 4 1 5 -4 0.2 80%Total 104 46 61 -15

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Table 7 indicates that whereas there are shortages of nurses in all the health centers (with Kayenje HCIII and Mutungo HC III having no nurses), there are excess 14 nurses in Nadiya GH according to workload – although the staffing norm for that facility calls for 73 nurses, only 26 are required according to the workload. The GH has a WISN ratio of 1.5 =150%. The fact that this facility is 50% overstaffed according to workload means that managers could consider shifting nurses to facilities that are short on nurses both by GOU standards and also according to WISN.

5.0 Institutional Arrangement and implementation Framework

Table 8 below outlines the roles of key institutions in line with their respective mandates. Each institution also has a designated responsible officer indicated.

At each level, these responsible officers are responsible for:• Appointing members of the WISN task team

• Deploying staff in the health sector

• Providing resources for WISN implementation

• Enforcing implementation of WISN guidelines

• Planning for recruitment or succession

• Submitting recruitment plans to MOPS

• Accounting for resources allocated for implementation of WISN activities

• Implementing policies, guidelines and recommendations of the line ministries regarding WISN

• Circulating the WISN guidelines and user manual and other relevant documents to all departments, and Units

• Deploying staff as recommended by WISN results

• Monitoring staff performance.

• Orienting the staff on WISN methodology

• Submitting HRH reports

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Table 8: Key Institutions and their Roles

Institution Responsible Officer

Roles of the Institution

Ministry of Public Service (MOPS)

Permanent Secretary - MOPS

1. Develops and reviews the establishment

2. Clears requests to fill vacant positions

3. Allocates wage to implement the approved establishment

4. Provides guidance on performance management systems

5. Reviews guidelines where necessary

6. Approves recruitment plans and wage requirements

7. Provides technical guidance in development and review of HRM guidelines and policies

8. Monitors WISN implementation in line with the public service human resource policies and regulations

9. Uploads and updates the approved establishment

10. Customizes the structures in line with the needs of a given MDA and local government

Ministry of Health (MOH)

Permanent Secretary – MOH

1. Develops, issues and reviews guidelines (including WISN guidelines) and standards for the health sector

2. Provides technical guidance in WISN implementation in health facilities and institutions

3. Plans and budgets for WISN activities for the health sector

4. Provides WISN user manuals for WISN implementation

5. Trains managers and users in the health sector

6. Provides data quality assurance at all levels for effective WISN implementation

7. Monitors WISN implementation

8. Deploys health workers to RRHs

9. Coordinates the collection and compilation of HMIS reports

10. Analyses WISN data to inform policy reviewsHealth Service Commission (HSC)

Chairperson HSC 1. Handles health worker disciplinary matters

2. Handles health worker promotions

3. Reviews terms and conditions of service and advises the MOPS accordingly

4. Offers technical guidance to district service commissions (DSCs) on recruitment matters

5. Recruits staff at the MOH, NRHs, and RRHs

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Institution Responsible Officer

Roles of the Institution

Ministry of Local Government (MOLG)

Permanent Secretary - MOLG

1. Monitors WISN implementation in local governments

2. Monitors human resources for health performance

3. Ensures timely submission of quarterly HRH reports

4. Advocates for HRH concernsMinistry of Finance, Planning and Economic Development (MOFPED)

Permanent Secretary - MOFPED

1. Provides financial resources for HRH

2. Monitors budget performance and enforces accountability for resources provided

3. Releases funds

District Local Government, Municipal Councils, Town Councils

Chief Administrative Officer – DLG; Town Clerk – Municipal or Town Council

1. Plans and budgets for WISN implementation

2. Prepares and submits periodic HR reports

3. Monitoring and reporting on implementation of WISN activity at the district level

4. Coordinating collection and compilation of HMIS reports

5. Developing recruitment plans and submitting to MoPS for clearance

6. Making submissions to DSC for recruitmentDistrict Service Commissions (DSCs)

Chairperson DSC working with the CAO

1. Recruits staff for DHO’s office, GHs and lower health units

2. Acts on recommendations of the accounting officers

3. Handles confirmation in services, staff promotions, granting study leave, disciplinary matters among others

Health Facilities Facility heads: Director- RRH, Medical Superintendent – GH and HCIV

1. Identifying the need for the WISN study

2. Planning and budgeting for implementation of WISN

3. Preparing and submitting periodic HR reports

4. Monitoring and reporting on implementation of WISN activity

5. Collection and compilation of HMIS reports

5.1 Other Key Players

There are other key players at the Districts, Municipalities, Town councils and Health facilities. These include the District Health Officers, Institutional Human resource officers, the Municipal Health officers, HMIS focal persons and In-charges of lower Health facilities. The responsibilities of these officers are out lined below but not limited to the list provided;

5.1.1 District or Municipality Health Officers/Heads of health facilities

1. Lead the WISN technical teams in the implementation of WISN methodology

2. Provide the necessary technical guidance regarding staff allocation and redeployment

3. Participate in capacity building/training of district WISN task force

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4. Monitor the performance of staff in the district/ municipal health sector

5. Participate in WISN calculations, analysis and interpretation of results

6. Provide schedule of duties and allocate tasks to staff

7. Prepare and submit relevant reports e.g.HR reports

5.1.2 HMIS Focal person

a. Capture accurate health information data

b. Analyse and provide information on health performance

c. Data quality assurance

5.1.3 Institutional Head of Human Resource

a. Participate in the WISN methodology to determine staff size for health facilities

b. Provide the necessary technical guidance on human resource matters

c. Implement staff -allocations in consultation with the institutional head of health services and heads of department

d. Provide the necessary human resource policy documents

e. Wage bill and payroll management

f. Update staffing norms based on the WISN methodology and submit requests for adjustment of staffing ceilings

6.0 Monitoring and Evaluation of Implementation of WISN guidelines

This section describes the monitoring mechanism that shall be followed while implementing WISN. Monitoring and Evaluation (M&E) focuses on measuring progress towards the achievement of set targets and outcomes. It also involves documenting lessons learned – both successes and challenges - from implementing WISN in the institution/facility so that management and key stakeholders are able to adopt strategies for improvement.

Proper M&E requires that baseline data is established to form the basis for periodic M&E of WISN activities for each institution or facility. M&E shall as much as possible be undertaken on a monthly, quarterly, biannual and annual basis. Data shall be collected by reviewing completed periodic HMIS reports as well as other reports. Additionally, site visits will be held for interviews, focus group discussions, observations and meetings with various stakeholders at the facility or institution. Reports shall be produced, and the findings discussed with the relevant stakeholders as a feedback mechanism.

The following indicators shall form the basis for M&E of WISN activities. In addition to the listed indicators, institution or facility-specific indicators may be developed and agreed upon to address unique circumstances. These are important indicators:

• Availability of trained WISN task team

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• WISN Equipment (e.g. computers, software, WISN tool)

• Availability and accessibility of WISN implementation guidelines and/or WHO Users’ Manual

• Level of employee satisfaction with their jobs or assignments

• Level of client satisfaction with services provided by the facility

• Availability and responsiveness of staff to clients

Outcome indicators shall measure attainment of the following key HRH results in an institution or facility:

• Decline in staff attrition

• Increased retention of health workers

• Decline in absenteeism

• Improvement in client satisfaction scores

Data Quality Management

Data quality assurance procedures shall be in place to ensure that the quality of data from the set system is reliable. These procedures shall confirm that data conforms to national and international standards of data quality including validity, reliability, precision, timeliness, integrity and completeness among others.

Strict data quality control procedures will be implemented in data collection, aggregation, analysis, storage, as well as confidentiality in reporting and dissemination of data. Routine data quality assessments will be conducted at primary data sources and aggregation sites to verify the accuracy of reported data. This will include reviewing institution databases and personnel records at the appropriate site/station e.g. DHO, PHRO, health facilities, MOH and IPs.

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Additional References

1, WHO WISN user’s Manual 2010

2, Applying the WISN Method in Practice case studies from Indonesia, Mozambique and Uganda, 2010

3, Heath Sector Development Plan 2015/16-2019/20

4, Activity Standards Handbook

5, Guidelines on Comprehensive Restructuring in Public Service, 2016

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