Health impacts of expanding different health workforce cadres under a limited budget in Malawi

Like many others, Malawis health care system faces significant health workforce shortages largely due to budget constraints that limit training, recruitment and retention of staff. A crucial question is how to best allocate a limited budget to expand different health care workers (HCW) cadres so that the potential health gains are maximised, which is more important now than ever considering recent withdraw and reduction in donor funding. This research aims to provide a practical answer to this question. We designed a range of budget allocation scenarios for HCW expansion across different cadres, and used the "all diseases - whole healthcare system" Thanzi La Onse (TLO) model to estimate the resulting population health outcomes. We find that, indeed, how to allocate additional resources for HRH across different cadres is an important determinant of potential health impact. Putting all resources into increasing staffing in a single cadre is not the most effective use of the resources, even if that cadre has the most limited availability currently. Similarly, allocating new resources in a manner that mirrors the current distribution of spending does not generate the greatest possible gains. Instead, an allocation that uplifts staffing for all cadres, according to extra time and cost required to meet the arising healthcare needs, gives the greatest benefits. We conclude that in the context of complex interplay between demography, epidemiology, treatment scope and effectiveness, and health resource constraints in the health care system, human resources for health (HRH) bottlenecks in achieving health gains are multifactorial and a balanced mix of cadres and skills is required for future HRH expansion. As such, health system models such as the TLO that capture this interplay can make potential contributions to strengthening HRH planning. What is already known on this topicTo date, very few studies have quantitatively analysed the potential future health impact of HRH expansion in the context of evolving healthcare needs for a whole population. One existing study shows that investing in HRH expansion has the potential to achieve better health outcomes for Malawians, assuming a uniform expansion of multiple cadres (1). What this study addsUnder a detailed individual-based simulation model capturing the wide range of healthcare needs and the interdependency between cadres for delivering care, we have shown that there is not a simple HRH bottleneck driving future health outcomes and health gains could be achieved by allocating additional resources to expand cadres in a carefully balanced way. How this study might affect research, practice or policyThis study answers the hard question of how to use the limited funding for HRH expansion to achieve greatest health gains in Malawi; and demonstrates the essential use of system-wide modelling to support decision-making in complex health systems.