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Human resources for health: a framework synthesis to put health workers at the centre of healthcare
  1. Ogonna N O Nwankwo1,2,3,
  2. Christian Auer1,2,
  3. Angela Oyo-Ita3,
  4. John Eyers4,
  5. Kaspar Wyss1,2,
  6. Günther Fink1,2,
  7. Xavier Bosch-Capblanch1,2
  1. 1Swiss Tropical and Public Health Institute, Allschwil, Switzerland
  2. 2University of Basel, Basel, Switzerland
  3. 3Department of Community Medicine, University of Calabar, Calabar, Nigeria
  4. 43ie London, London, London, UK
  1. Correspondence to Ogonna N O Nwankwo; drogonnanwankwo{at}gmail.com

Abstract

Background Human resources are a key determinant for the quality of healthcare and health outcomes. Several human resource management approaches or practices have been proposed and implemented to better understand and address health workers’ challenges with mixed results particularly in low- and middle-income countries (LMICs). The aim of this framework synthesis was to review the human resources frameworks commonly available to address human resources for health issues in LMIC.

Methods We searched studies in Medline, Embase, CAB Global Health, CINAHL (EBSCO) and WHO global Index Medicus up to 2021. We included studies that provided frameworks to tackle human resources for health issues, especially for LMICs. We synthesised the findings using a framework and thematic synthesis methods.

Results The search identified 8574 studies, out of which 17 were included in our analysis. The common elements of different frameworks are (in descending order of frequency): (1) functional roles of health workers; (2) health workforce performance outcomes; (3) human resource management practises and levers; (4) health system outcomes; (5) contextual/cross-cutting issues; (6) population health outcomes and (7) the humanness of health workers. All frameworks directly or indirectly considered themes around the functional roles of health workers and on the outcomes of health workforce activities, while themes concerning the humanness of health workers were least represented. We propose a synthesised Human-Centred Health Workforce Framework.

Conclusions Several frameworks exist providing different recurring thematic areas for addressing human resources for health issues in LMIC. Frameworks have predominantly functional or instrumental dimensions and much less consideration of the humanness of health workers. The paradigms used in policy making, development and funding may compromise the effectiveness of strategies to address human resources challenges in LMIC. We propose a comprehensive human resources for health framework to address these pitfalls.

  • Systematic review
  • Health policy
  • Health systems
  • Health services research

Data availability statement

With the exception of the data extraction sheets, all data relevant to the study are included in the article or uploaded as a supplementary file. The data extraction sheets are available on request to the corresponding author.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2023-014556

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Human resources for health are the cornerstone of good quality of health services delivery, at the heart of Universal Health Coverage; yet, they face severe challenges for decades. Understanding the underlying paradigms supporting Human Resources for Health (HRH) interventions and policies may likely be part of the problem and of the solution to these challenges. However, there is paucity of evidence on human resource management paradigms or frameworks used to address or intervene in HRH in low- and middle-income countries.

    WHAT THIS STUDY ADDS

    • The findings suggest that the existing frameworks, alongside the seven common thematic areas, focus on the ‘instrumental’ dimensions of human resources, paying much less attention to issues related to their ‘humanness’. Based on our synthesis, we propose a comprehensive human-centred HRH framework.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Applying a comprehensive, human-centred HRH framework will unveil all dimensions of HRH, placing health workers at the very core of the health system. Considering the centrality of health workers' ‘humanness’, research, policy and implementation on HRH will become more relevant and result in better outcomes.

    Background

    Human resources for health are one of the most important determinants for the quality of healthcare services delivered to populations1–4 and one of the health system pillars.5 Despite their crucial importance, human resources for health remain scarce: it is estimated that by 2030, there will be a shortage of 10 million skilled health workers across the globe6 with countries in the WHO African region projected to constitute 52% of the global shortage by then.6 This shortage is further widened in many low- and middle-income countries (LMICs), where there are high rates of emigration of their trained health workers to more developed countries (‘brain drain’), due to numerous factors including low salaries, poor working and living conditions or low quality of life outside the workplace.7 The estimated global physician density is 10-fold compared with the physician density in sub-Saharan Africa.8

    To make things worse, in many countries, there is a maldistribution of health workers, with most of them deployed in urban areas to the detriment of rural areas, which are disadvantaged in many socioeconomic aspects.9 10 Health workers in rural areas, who are at the frontline of the patients in the health services, are faced with myriads of problems stemming from the workplace itself, from the lack of infrastructure, limited opportunities and options for continuous education and enablers for their personal and family well-being.9–12 All of these challenges can affect their motivation and satisfaction with work, their psychological status and their work performance.

    Generally, health managers and policy makers expect to obtain the highest possible performance from their health workers as part of achieving the national or subnational health system targets. Health workers’ performance is a relatively comprehensive construct encompassing availability, clinical competence, responsiveness (ie, providing patient-centred care) and productivity or efficiency.2

    Organisational arrangements and interventions to address health workforce issues are, therefore, critical to improve the quality of clinical and public health services. Several human resource management (HRM) approaches or practices have been proposed and implemented13 to better understand health worker challenges and to tackle them in order to improve their performance and, consequently, the care they provide. These arrangements are based on paradigms that define how human resources for health should be understood in relation to the overall health system setup and context. For example, the ‘Managing for Performance’ framework was developed using a global collaboration of insights from different actors and avails a model that predominantly understands health workforce in its functional role.14

    Different frameworks harbour different ways of understanding the human resource for health (HRH) issues. For example, human resources may be understood within a managerial perspective (eg, human resources are ‘a piece’ in the management organisation of the system) or focus on their ‘humanness’, as is the case in an emerging conception in the field of human resources that stresses the well-being of health workers as key contributors in achieving the ultimate goal of improving the outcomes of an organisation.15 16

    This latter paradigm predominantly looks at the psychological dimension that plays a role in determining decisions, outputs and productivity, which ultimately decides workforce performance.17 18 This is important in considering the ongoing drive to move health systems towards a people-centred outlook, where the delivery of healthcare is built to fit end-users in their circumstances and environment.

    Not surprisingly, despite the long-standing knowledge of the issues affecting healthcare service provision, the situation of health workers does not seem to have substantially improved in recent years;19 there is neither a known effective approach to address the numerous challenges facing health workers’ performance.3 20

    Hence, there is a need for systematically reviewing and synthesising the different frameworks that exist for HRH and to examine the focus and limitations of such frameworks. This will aid in the identification of potential gaps or even misconceptions within the different frameworks in understanding and tackling HRH issues in LMICs.

    We hypothesised that there are different underlying human resource paradigms available for determining how health workforce problems are identified, described and how interventions to address them are ideated, designed and implemented. In order to inform this hypothesis, we carried out a framework synthesis addressing the following question: what HRM paradigms or frameworks are used to understand or intervene in human resources for health in LMICs and what are their characteristics?

    An earlier systematic review focused on describing measurement approaches of human resources systems, selecting only empirical studies using quantitative methods and published in high impact factor journals, including non-health related human resources.21 This earlier review, though, did not explore the underlying conceptual paradigms used in relation to HRH.

    Methods

    We used a systematic review and framework synthesis approach to synthesise the evidence on human resources frameworks. The protocol for this systematic review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO—CRD42020216247)22 and the reporting of the review is compliant with the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines.23

    Criteria for considering documents reporting frameworks

    The eligibility criteria were developed following the SPIDER approach,24 as follows:

    Sample: LMIC, based on the World Bank classification.25 We excluded studies intended for, carried out or applied to only high-income countries.

    Phenomena of Interest: human resources for health management frameworks applied, for example, to human resources for health challenges or for improving health workers performance.

    Design: all research and conceptual study design types were considered, except opinions, editorials or studies without an explicit research methodology.

    Evaluation: frameworks that were used in addressing the human resources for health challenges, drawing out concepts or lessons learnt, findings and perceptions relating to human resources for health management frameworks in tackling health worker challenges.

    Research type: qualitative studies, mixed-methods studies and any other study producing data related to the review question.

    Although we had originally proposed in our protocol to exclude articles not entirely written in English at the level of full text screening, we eventually considered every identified article at this stage.

    Information sources and search

    We searched five relevant databases across the health, health systems and global health literature (Medline, Embase, CAB Global Health (covers grey literature), CINAHL (EBSCO) and WHO global Index Medicus (for grey literature). Based on this strategy, one of the authors (ONON) conducted snowballing searches over the selected articles’ references to identify additional references.

    Search strategy

    The strategy involved search terms extracted from the research question for keywords such as ‘health workforce’, ‘organisational policy’, ‘frameworks’, ‘low income countries’ and ‘lower middle-income countries’ in the title and abstract. The keywords were adapted and applied to each database. The search strategy, including the full search strings used for all the different databases, is detailed in the supporting documents (online supplemental material 1). Additionally, citation searches were carried out on key references to identify additional relevant articles, while we also tried to identify additional articles by contacting experts. No date restriction was applied to the electronic databases searches.

    Supplemental material

    Data collection and analyses

    Data management and selection process

    All retrieved references from the databases were exported to EndNote V.X9,26 where removal of duplicates was automatically carried out and manually verified. Thereafter, remaining titles and abstracts were screened for relevance performed by one of the reviewers (ONON).

    The full text of relevant references were obtained and the inclusion/exclusion criteria applied with a second reviewer (CA) checking some articles, either because of doubts by the first reviewer or carrying out arbitrary checks. Where doubts or disagreements in inclusion of an article persisted after the discussion between the two reviewers, a third reviewer (XBC) made the inclusion or exclusion decision.

    Data collection and data items

    We developed a data extraction form in a Microsoft Excel workbook to extract and enter the data from the included studies. Key characteristics of the paper extracted included authors, year of publication, countries, study design, HR framework name, healthcare workers (HCW) type, the problem(s) targeted by the framework, objectives of the study and methods used in developing the framework. Terms used to describe the elements in the frameworks and the hierarchical order of relationship of the terms as described or illustrated there were also extracted. Data extraction was done by the first reviewer (ONON) which was validated by another reviewer (XBC). The data relevant to the review were drawn from discursive texts that reflected the paradigms used in human resources for health, in line with the earlier methods set out by Brunton and colleagues.27 Although we required the included studies to have a methodological approach, we did not aim at assessing their quality or risk of bias.

    Data synthesis

    Terms were derived from the included frameworks and were grouped to show their interconnections and relationships, as described in each of the frameworks. Subsequently, the different terms and their relationship were grouped according to similarities across different frameworks. Relationships were further worked out to establish links between subthemes and themes, using network plots (online supplemental material 2). The emerging themes were examined in the light of the original questions, the wider research literature and the context in which the study was originally undertaken.

    Supplemental material

    We carried out both framework and thematic syntheses28–30 from which we elaborated the ‘Human-Centred Health Workforce Framework’. This was carried out in several steps encompassing line-by-line coding of each framework and its accompanying terms and aggregation of similar codes into themes. A more detailed explanation of how this was done can be seen in the supporting document (online supplemental material 2).

    We also reviewed each framework in the light of the distinction between ‘hard’ and ‘soft’ Human Resources Management (HRM).31 32 ‘Hard’ HRM views workers primarily as resources or entities to be used or handled in achieving organisational goals and focuses on the ‘labour capacity’ of workers. Conversely, ‘soft’ HRM views workers as human means rather whose commitment needs to be won in order to achieve organisational goals, thus elevating them to the position of stakeholders. We categorised the frameworks according to these categories.

    Finally, in order to elaborate a more relevant Health Workforce Framework—the ‘Human-Centred Health Workforce Framework’, we have considered (1) previous learnings on Human-Centred Design applied33 and (2) balancing the different dimensions or domains of existing frameworks. This was further discussed with coauthors and the PHISICC team researchers in Nigeria to reach consensus.

    Patient and public involvement

    Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

    Results

    The search strategy retrieved 8563 hits across different databases, while 11 articles were from additional sources from manual secondary reference searching of selected articles for full-text screening. After removing duplicates, we screened 6464 records for relevance, and the full text of 212 records were further scrutinised for inclusion. 195 of these 212 articles were excluded, the main reason being the absence of a framework, having frameworks not focusing on human resources for health, or not focusing on LMIC. Seventeen studies met our inclusion criteria and were included in our analysis (figure 1). The characteristics of included studies are seen in online supplemental material 3. The table in the online supplemental material 4 lists the excluded studies and reasons for exclusion. Note that included references in the Results section are cited with the first author name and the publication year and the full citations are found in online supplemental file 2.

    Supplemental material

    Supplemental material

    Figure 1
    Figure 1

    PRISMA flowchart of studies. PRISMA, Preferred Reporting Items for Systematic reviews and Meta-analyses.

    Characteristics of included studies

    The included articles were published between 2004 and 2020. Six of the articles were specifically written for LMICs (Dieleman 2009; Fujita 2011; Lehmann 2008; Mathauer 2006; Raven 2015; Roome 2014), three focused on a specific country—India, Indonesia and Malawi (Kurniati 201; Jacob 2020; Lohmann 2019), respectively, while eight articles focused on all countries including LMICs (Campbell 2013a; Campbell 2013b; Gross 2012; Huicho 2010; Joint Learning Initiative 2004; Sousa 2013; MSH 2009, WHO 2006).

    10 of the 17 included articles were led by authors from high-income countries (Campbell 2013a; Campbell 2013b; Dieleman 2009; Fujita 2011; Gross 2012; Lohmann 2019; Mathauer 2006; Raven 2015; Roome 2014; Sousa 2013); two by authors from upper middle-income countries (Huicho 2010; Lehmann 2008) and another two by authors from LMICs (Jacob 2020; Kurniati 2015). Three of the 17 publications were issued by international organisations (Joint Learning Initiative 2004; MSH 2009, WHO 2006).

    Twelve of the selected articles had a name for each of the framework described, such as ‘HRH action framework’, ‘AAAQ dimensions of health workforce’, ‘The integrated causal model. HR: human resource’, ‘House model framework’ and ‘Conceptual framework for measuring efforts to increase access to healthworkers in underserved areas’, respectively (MSH 2009, Campbell 2013a, Jacob 2020, Fujita 2011; Huicho 2010).

    Six of the articles mentioned some specific health worker categories in the framework, such as frontline health workers; primary HCWs; nurses; medical doctors, professionally trained health workers; although, broadly speaking, there were no restrictions on the types of health workers the frameworks would apply to (Dieleman 2009; Jacob 2020; Kurniati 2015; Lohmann 2019; Raven 2015; Mathauer 2006).

    Ten of the identified frameworks were developed using mixed methods, including review of previous frameworks, narrative and literature reviews, case studies, expert consultations, insights from primary studies (Dieleman 2009; Fujita 2011; Gross 2012; Huicho 2010; Jacob 2020; Joint Learning Initiative 2004; Kurniati 2015; Mathauer 2006; Roome 2014; MSH 2009). One study did not clearly describe how the framework was developed although it could be deduced that it was using mixed methods including some literature review and consultations (WHO 2006), while the others were based majorly on theoretical or conceptual underpinnings (Campbell 2013a; Campbell 2013b; Lehmann 2008; Lohmann 2019; Raven 2015; Sousa 2013). Two of the 17 studies were carried out with the perspective for conflict or postconflict settings (Fujita 2011; Roome 2014). The Human Resources for Health Action Framework by WHO (MSH 2009; WHO 2006) is the framework most commonly mentioned or referenced by the other included studies.

    The brief description of each of the 17 frameworks is fully developed in the supplementary materials (online supplemental material 2).

    Framework synthesis

    In the following paragraphs, we synthesise the frameworks according to a series of themes. The themes from the thematic analysis are charted for each of the framework in table 1. A high-level analysis of existing frameworks suggests that there are seven major themes that the concepts and terms of the frameworks embrace at varying degrees.

    View this table:
    Table 1

    Thematic synthesis of the frameworks

    From the thematic synthesis, the presence of the different themes was, by order of frequency (based on explicit mention): (1) the functional roles of health workers (17, 100%), (2) health workforce performance outcomes (16, 94.1%), (3) HRM practises and levers (16, 94.1%), (4) health system outcomes (12, 70.6%), (5) contextual/cross-cutting issues (12, 70.6%), (6) population health outcomes (6, 35.3%) and (7) humanness of health workers (6, 35.3%).

    Overall, four of the studies (Dieleman 2009; Huicho 2010; MSH 2009; Roome 2014) explicitly or implicitly had the highest representation of six out of the seven themes, while two of them (Jacob 2020, Raven 2014) had many themes absent.

    In detail, themes on the functional roles of health workers tend to be (over)ambitious in their functions and scope, in line with the statement of the WHO report 2006 (WHO 2006): ‘In tackling these world health problems, the workforce goal is simple—to get the right workers with the right skills in the right place doing the right things!—and in so doing, to retain the agility to respond to crises, to meet current gaps, and to anticipate the future’ (page xx). The terms related to the functional roles of health workers tend to be rather instrumental for health service delivery (eg, ‘health workers’ ‘use’, ‘roles’, ‘physical functioning in the workplace’).

    Themes on health workforce performance outcomes were related to the expected outcomes/indicators for HRH by managers of the health system, such as availability, quality, motivation and competence, among other dimensions. This is consistent with the World Health Report 20062 (WHO 2006) statement: ‘A central objective of workforce development is to produce sufficient numbers of skilled workers with technical competencies whose background, language and social attributes make them accessible and able to reach diverse clients and populations’

    Themes on the HRM practices and levers pointed at the tools and practises health managers can implement in seeking to achieve their overall health goals, having health workers as one of the management resources they have at hand, for example, staffing, monitoring and evaluation or deployment.

    Terms used in describing the theme on health system outcomes include quality of care, effective coverage, equity, Universal Health Coverage, among others. These terms are usually constructs based on ideal goals, values and strategic visions, usually issued by governments or international coalitions of governments that are proposed as performance measure frameworks in different health system domains.5 Considering outcomes may require the integration of one or more pillars of the health system, such as service delivery, HRH, governance and financing, as well as intersectoral collaborations, for example, between ministries of health and finances and social welfare, in order to keep goals relevant. For example: ‘… strategies and actions in each of the AAAQ dimensions of HRH have brought about improvements in quality of care and effective coverage and these have resulted in better health outcomes … Each country aims for a workforce that is fit for purpose and fit to practise—made possible by whole-of-government approaches prioritising equitable, efficient and effective health services’ (Campbell 2013a, page 858).

    Some cross-cutting, rather contextual themes were hardly found in the frameworks: issues related to conflict areas, governmental policies, environmental, legal and policy issues or cultural contexts. These are themes that may not be always key in the remit of the health sector but impact in one way or another under health sector and human resources policies.

    The theme on the population health outcomes is found using a few commonly used terminology, such as ‘health status’ or ‘improved health’.

    The theme around humanness of the health workers tends to focus on subjective issues, such as the subjective well-being, the meaning and purpose of life,34 the links with their ‘work related well-being’, ‘the overall quality of an employee’s experience and functioning at work’ and concerns for the psychological, physical and social functioning of health workers.18 The ‘will-do’ aspect of the internal psychological process of the worker concerns the establishment of congruence between personal goals and the goals of the organisation (goal setting) (Mathauer 2006). For example: Questions that characterise this psychological process are: ‘What is the personal value of devoting more of my resources to the job?’ or ‘What is the personal value of achieving higher job performance?’ The ‘can-do’ aspect of the internal psychological process of the workers concerns motivational effectiveness, the extent of individual resources that are mobilised to accomplish adopted goals (goal achievement). The related question is: ‘How likely is it to achieve the desired level of job performance?’" (Mathauer 2006). Again, the theme on humanness of the health worker also encompasses the personal characteristics and circumstances of the health worker which can affect their functioning optimally in their role such as gender, diversity, age, socioeconomic status, etc. ‘Gender’ and ‘age’ were sparsely mentioned by four of the frameworks, while none of the frameworks mentioned other terms like ‘diversity’ and ‘socioeconomic status’.

    Discussion

    We have carried out a synthesis of human resources for health frameworks focusing on LMIC. We synthesised 17 frameworks that are used in understanding and/or addressing the human resources for health challenges and interventions. Overall, managerial or instrumental dimensions of human resources for health tend to dominate over health workforce psychological dimensions and well-being. Although it is not the first time that this type of imbalance has been observed,35 our approach is the first systematic and most comprehensive approach to document this issue. One of the studies that best attempted in covering the themes directly affecting health workers (ie, humanness of HCW and functional role of HCW) together with managers’ expectations (ie, health workforce performance outcomes) was the study by Raven and colleagues (Raven 2015).36

    Globally, it is recognised that health workers’ difficulties to practice in challenging and difficult conditions, such as in underserved, remote, rural areas, is a major limitation to the achievement of equitable access to health services and provision of good quality of care to the population (Huicho 2010).37 However, most of the frameworks identified described problems and potential solutions as if the subjective experiences, socioeconomic and personal contexts of health workers were not so decisive. This outlook seems consistent with the concept of ‘hard’ HRM, which approaches health workers as one of several categories of the resources of the health enterprise (eg, financial resources, equipment, etc.) that will determine the output and achievement of organisational goals.38 On the other hand, the ‘soft’ HRM approach understands human resources as the most important singular element in the system and seeks to optimise it by being more health workforce centred and focusing on the work environment, as well.39 The ‘soft’ HRM approach is meant to cover as well, some intangible elements, such as the ideas and interests, values and norms, and affinities and power of health workers, which shape actions and behaviours and underpin the relationships among health system actors and components.40–42 This concept acknowledges that the behaviours and decisions of people are underpinned by their ‘worlds’ or lived realities,39 43 which can be appreciated and realigned in favour of broader health system goals. This opens the perspective of improving the performance and practice of health workers by addressing the intangible ‘software’ components of the health system as well as those of health workers.

    Our findings imply that policy makers, managers, funding agencies and researchers may be, explicitly or implicitly, applying functional and mechanistic paradigms when dealing with human resource issues. This should not be surprising as it has been previously pointed out that the health system has traditionally been understood in instrumental or functional terms, overlooking its intricate and variable attributes that are dynamically shaped by human agency at all levels.44

    Although the attribution of successes or failures of complex health system interventions is rather difficult if not controversial in the absence of strong evidence, we deem it reasonable to consider that the prevalent HRH paradigms may have contributed to the failure of current human resource strategies in solving the HRH challenges globally. On the other hand, there are examples that suggest how the humanity of health workers can be brought into play. A study commissioned by WHO illustrates how some aspects of humanness can influence the performance of the health workers.36 Another study suggested that health workers’ frustration was their inability to fulfil their conscience and values in their workplace due to contextual issues.35 Also, our recent experience in involving frontline human resources in the ideation and testing of a health systems intervention has shown to which extent putting health workers at the centre of the system brings extraordinary gains, in terms of understanding problems and designing solutions.33 This is an example in keeping with positions that advocated for working with ‘intangible software’ in public health systems.41

    Finally, it was striking that other crucial issues bordering within the remit of the humanness of health workers—personal characteristics—such as gender or diversity, were hardly present in the examined frameworks, while these are issues that are more and more becoming common practices in other domains, such as for researchers.45

    The Human-Centred Health Workforce Framework

    Based on the different frameworks reviewed, the thematic analysis done showing several thematic areas (figure 2) and our previous learnings, we propose a framework synthesis of the major paradigms and themes around human resources for health (figure 3).

    Figure 2
    Figure 2

    Representation of the ‘managerial’ frameworks towards Health Workforce.

    Figure 3
    Figure 3

    The Human-Centred Health Workforce.The new framework in figure 3 compared with figure 2 highlights the humanness components in orange arrows and red tone colour. The difference between this new framework (figure 3) compared with the old one (figure 2) lies in highlighting additionally the often overlooked path of implementation of HR strategies/interventions targeting the humanness of health workers (empowerment of health workers to proffer solutions to the problems and challenges witnessed in the HRH). This is not in keeping with the conventional method as seen in figure 2, which targets interventions towards health workers' functional roles and may seem to overlook health workers' humanness. The new framework highlights the prime recognition of the agency of health workers and the need for implementation of rewiring of the ‘intangible software’ of the health system unlike the conventional method which seeks for implementation of strategies targeting the hardware of the health system, for example, human resource, finance, service delivery, etc, based on their utility as a resource for achievement of desired health outcomes. The new framework in figure 3 compared with the previous ones (figure 2) highlights all seven thematic areas synthesised from all the 17 frameworks reviewed in a vivid form while providing the linkages of each theme to one another and yet brings to the fore the place of human agency (humanness theme) in issues related to HRH (coloured in orange and red tone).

    This framework brings to the fore the central role that health workers have to play in achieving the ultimate health systems goals of good population health outcomes, while drawing attention to an often overlooked critical issue—the humanity of health workers. Furthermore, it systematically shows the aggregation of the different component areas from the previous 17 frameworks, usually interwoven in a complex relationship in a continuum.

    Limitations

    As in any systematic review, we have to acknowledge the potential of having missed relevant studies. To minimise this issue, we also carried out secondary reference checks. We believe that the scope, variety and depth of our findings would not be substantially modified by additional evidence that we might have missed, as we experienced a certain degree of saturation and repetition of terms and concepts reported.

    The thematic analysis has a subjective component that we have tried to minimise through frequent exchanges between researchers in relation to the data extracted, the network plots and the overall synthesis. The newly synthesised framework will benefit from validation.

    Our search of grey literature was limited to CAB Global health and WHO Global Index Medicus. We would not expect any relevant frameworks not to have been published or not having been already found in the searched databases.

    Conclusion

    Our work has shown that despite there being several paradigms and frameworks available for providing insights into the issue of HRH which provides several recurring thematic areas of consideration, there is under-representation of the thematic areas of the humanness of health workers in most. This theme is at the core of achieving the health system goals of population health recognising the agency of health workers who are capable of self-control, learning, conceptualisation, collaborating and adapting to and leading change.41 Based on our synthesis, we have proposed a Human-Centred Health Workforce Framework which points to the important functional roles of health workers in the health system while highlighting their unique attribute of humanness. Placing health workers at the very core of the health system would mean additionally recognising their unique attribute of humanness compared with other resources needed for actualisation of the health system goals; such that they are given a voice to participate in the decisions affecting them and their roles as key contributors to communities' well-being and development among others is prominently recognised.

    Data availability statement

    With the exception of the data extraction sheets, all data relevant to the study are included in the article or uploaded as a supplementary file. The data extraction sheets are available on request to the corresponding author.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

    Acknowledgments

    We want to thank professor Martin Meremikwu and Dr Nnette Ekpenyong of the University of Calabar for their support and Damaris Rodriguez Franco of the Sonder design for aiding in further refining the graphics of the framework.

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    Supplementary materials

    Footnotes

    • Handling editor Helen J Surana

    • Contributors ONON, AOI and XBC conceptualised the study. JE implemented the search strategies. ONON, CA and XBC were involved in the screening, data extraction and analysis of the study. ONON, CA, AOI, XBC, JE, KW and GF contributed to the interpretation of the results. The initial draft of the manuscript was written by ONON. All the other authors critically reviewed the manuscript. All authors approved the final draft of the manuscript. All authors had final responsibility for the decision to submit for publication. ONON is the guarantor of this article.

    • Funding ONON's PhD has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement no. 801076, through the SSPH+ Global PhD Fellowship Programme in Public Health Sciences (GlobalP3HS) of the Swiss School of Public Health. The funders had no role in the conception or implementation of this review.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.