CapacityPlus improved human resources for health (HRH) measurement and monitoring and evaluation capacity and developed an HRH Effort Index to spur policy changes and enable cross-country comparisons.

Background
Accurate and timely information for decision-making and advocacy is a key system component in strengthening human resources for health (HRH) toward achieving the goals of AIDS-Free Generation, Ending Preventable Child and Maternal Deaths, and Family Planning 2020. However, indicators used to measure efforts and progress in HRH have been limited and often unreliable, especially in countries with weak or no monitoring and evaluation (M&E) plans and/or human resources information systems (HRIS). Such limitations prevent or severely constrain country, donor, and program initiatives to identify and address gaps in HRH and to track progress over time. The skilled health professionals density ratio (SHPDR), which measures the number of physicians, nurses, and midwives per 10,000 population (Campbell et al. 2013; World Health Organization [WHO] 2006;) and the health worker reach index, which incorporates the SHPDR and measures of access to and actual use of services provided by health workers (Save the Children 2011) are two indicators that have increasingly been used to measure progress in improving the health workforce. Yet both indicators are limited by variable data quality and by the fact that they exclude certain cadres of health workers, such as auxiliary and community health workers. These limitations hinder the measures’ utility in understanding the relationships between HRH inputs, service use, and health outcomes. CapacityPlus helped to bridge these gaps by developing a more robust measurement approach to assessing the complex framework for HRH—the  HRH Effort Index—and by increasing capacity for M&E of HRH at the country level through improved measurement approaches and M&E skills.

Strategy and Approaches
CapacityPlus developed the HRH Indicator Compendium, which provides a summary of standardized indicators in the areas of global leadership; health workforce policy, planning, and management; health workforce development; and health workforce performance support. HRH stakeholders can use the Compendium to identify indicators to monitor the HRH situation in their countries. The Compendium details how the varied indicators (e.g., rates, ratios, and indices) can be calculated.

To complement the Compendium, CapacityPlus developed M&E Guidelines for HRH, which address the need for a conceptual framework for any HRH intervention, guiding the reader through the domains of interest (e.g., from overarching policies to the health facility level) and the logical steps (from inputs and processes to outputs and outcomes) to ensure that a solid M&E plan is formulated (including indicators and data collection methods) to measure progress and results of HRH interventions.

The project also published an eLearning course, An Introduction to Monitoring and Evaluation of Human Resources for Health, on the HRH Global Resource Center to provide stakeholders with the essentials on M&E of HRH and inform them about tools and resources to develop M&E systems and plans.

To better inform HRH investments and support more equitable health systems, the project developed the HRH Effort Index (modeled after the Family Planning Effort Index), using the HRH Action Framework as a conceptual guide and inputs from an international advisory group (including USAID and WHO), reviews of the relevant literature, and interviews with HRH experts in Mali, Nigeria, Uganda, and the Dominican Republic. The Index guides key informants through a self-administered survey tool covering 50 items across seven HRH dimensions identified in the HRH Action Framework: leadership and advocacy; policy and governance; finances; education and training; distribution, recruitment, and retention; human resources management; and monitoring, evaluation, and information systems. The informant answers by scoring their assessment of the extent to which each item has been developed and/or supported, based on a scale of 1 to 10.
 
Individual responses are averaged per dimension and also to produce an overall “index” of HRH effort. The main application of the Index is through a survey to experts from different sectors (e.g., public, private, nongovernmental organizations [NGOs], faith-based organizations [FBOs]) and institutions (e.g., Ministry of Health, professional associations, professional schools, academia) gauging efforts at the national level. However, other applications can include surveys at sub-national (e.g., province, county) levels and group or consensus meetings, where stakeholders score and discuss each item, dimension, and the overall score as a way to identify strong and weak areas of HRH investment and effort, with evident buy-in and capacity-building potential. User feedback from a pilot test of the Index in Kenya and Nigeria in 2014 informed final revisions to the tool, which was subsequently applied in several countries through a variety of modalities: individually for national (Dominican Republic, Mali, and Ghana) and subnational (Dominican Republic) scopes, and collectively through a consensus meeting of stakeholders (Mali).

CapacityPlus also conducted several evaluations of innovative HRH investments that generated much-needed evidence. These used a variety of methods including a pre- and post-intervention design in the pilot of an mHealth family planning in-service training application among health workers in Senegal to foster retention of training content. The evaluation demonstrated improved knowledge of family planning side effects 10 months after the training. In Nigeria, the project obtained and analyzed existing data available from the community health and midwifery associations to assess the effectiveness of support to preservice education institutions and students in increasing the number of newly qualified health workers, and complemented these results with additional primary data collection at schools that received support, among key preservice education stakeholders involved in the processes, and with scholarship recipients. In Uganda, the project linked HRIS data with client record systems such as DHIS 2 to elucidate the association between increases in the health workforce and changes in service delivery.  Where baseline values were lacking, the project innovated by conducting retrospective or reconstructive evaluations (e.g., effects of human resources management policy and practice interventions among Kenyan FBOs).