We want to briefly share with you the experiences of our team in Uganda in using a great management tool and methodology called the Workload Indicator of Staffing Needs, or WISN for short. WISN, which was developed by the World Health Organization, helps calculate the number and types of staff a health facility needs based on:

• The time it takes to carry out an activity to the professionally acceptable standard
• The available working time, i.e., the time that a health worker is actually available for work
• The workload of the facility based on available service statistics.

In Uganda, the Ministry of Health had been setting staffing guidelines based on fixed staffing patterns depending on the type of facility, not the actual usage of the particular facility. Recognizing that this system was not giving all facilities the numbers and types of health workers needed to meet patient demand, the Ministry of Health undertook a workload analysis in eight districts, with support from IntraHealth’s Uganda Capacity Program. The analysis aimed to determine the most efficient way to employ the available skilled health workers and offer better staff equity and health services, including HIV/AIDS care. The analysis determined that in health facilities in these districts:

1. Overall, there was a shortage of all cadres of staff, but especially doctors and nurses, who are critical for many health services.    
2. Although all staff members sometimes work under pressure, nurses and midwives in health centers were under very high work pressure while their counterparts in hospitals worked in a less demanding environment. This meant that redeploying staff to the district health centers could better distribute the workload, reduce work pressure, and improve services. In most districts, however, it is difficult to redeploy to another location for political reasons and because of the existing fixed facility level staffing norms.
3. After analyzing the workload at health centers, it is clear that the current norms recommend too few nurses and midwives at the health centers although the recommendations for clinical officers and nursing assistants are close to meeting the workload demands.
4. In districts without general hospitals, the workload at health centers is very high, and the WISN analysis showed that these facilities need significantly more doctors and clinical officers than the current guidelines recommend. 
5. The pressure on overworked staff could be reduced by recruiting additional staff, even in keeping with the current staffing guidelines, but the districts did not have the funds to do so. 
6. Generally, clinical officers and nursing assistants were working under minimal pressure at all levels of the health facility.

Currently, Uganda has one health worker for every 818 people as compared to the World Health Organization’s recommendation of a minimum of one health worker for every 439 people. Furthermore, health workers in Uganda are heavily concentrated in urban areas, where only 12% of Ugandans live. The Ugandan Ministry of Health is aiming to achieve an adequate, appropriately skilled, and equitably distributed health care workforce that is responsive to the needs of the people. It is clear that to realize this vision, Uganda must use the health workers it has more efficiently, ensure a more equitable distribution of workload among the available personnel, and grow its health workforce.

So how can Uganda get there?

One answer is making evidence-based decisions to reallocate workers based on workload using WISN methodology. In our case, we shared our results with the each district’s political and technical leaders. Many of them say they really welcomed this kind of data and that it helped them better understand the need for staff redeployment. We also helped the district leaders to come up with the following recommendations based on the study findings:

• Redeploy current staff members to ensure that they are placed where they are needed most and so that workload is distributed fairly among staff
• Advocate for recruiting additional staff to ease the work pressure, using the WISN results as supporting evidence
• Advocate for using national workload-based staffing norms rather than facility-based norms.

We also shared these findings at the 54^th East, Central and Southern African Health Community Health Ministers Conference in Mombasa in November 2011. As a result, the ministers resolved to promote the use of workload-based methods to determine staffing norms rather than fixed facility norms. IntraHealth is also continuing its collaboration with the Ugandan Ministry of Health to obtain representative and statistically significant WISN results to inform policy revision from fixed to national workload-based norms at the national level by collecting data from more districts and health units.