Surge capacity refers to a health system’s ability to respond to sudden increases in patient care demand by rapidly adapting its “staff, stuff, space, and systems.”Reference Watson, Rudge and Coker 1 –Reference Thomasian, Madad and Hick 5 This capacity has been essential in effectively addressing the COVID-19 pandemic. A critical aspect of surge capacity is the ability to sustain increased human resources for health (HRH) during a crisis, which will be vital for managing future crises. Being able to sustain increase HRH numbers in a crisis is a critical component of surge capacity and will be a key to responding to future crises. Countries in South Asia regularly cope with health workforce shortages, skill-mix imbalances, unequitable distribution, migration, and worker retention. 6 , Reference Sommer and Mosley 7
South Asian countries have extensive experience learning from epidemics and disasters. Joint external evaluations (JEE) of pandemic preparedness were completed prior to the pandemic for Bangladesh 8 and Sri Lanka, 9 with Nepal 10 completing its evaluation in 2022. These evaluations underscore the ongoing efforts and challenges in enhancing surge capacity and pandemic preparedness in the region.
Human resources for health had been inadequate in the three countries even prior to the pandemic: in 2019, Sri Lanka had 1.2 doctors and 2.3 nurses per 1000 people, Nepal had 0.8 doctors and 3.3 nurses per 1000, and Bangladesh had 0.6 doctors and 0.4 nurses per 1000. These figures fall below the recommended threshold of 4.45 health workers per 1000 population needed to achieve the sustainable development goals (SDGs) outlined in the WHO Global Strategy on Human Resources for Health: Workforce 2030. 11
Sri Lanka’s health workforce has taken decades to recover from the significant declines experienced during the armed conflicts of the 1990s. Despite numerous efforts to bolster HRH capacity, growth in health sector employment has lagged behind other public sectors and neighboring countries. 12 Bangladesh and Nepal have also faced severe shortages of health workers, with pronounced disparities between rural and urban areas and stagnating growth rates in the health workforce over the past decade.Reference Das Pooja, Nandonik and Ahmed 13 , Reference Sherchand 14
The pandemic exacerbated these existing challenges, placing immense additional strain on health systems to meet the rising demands for acute and critical care. Furthermore, the health workforce faced significant threats from exposure and quarantine requirements, family illness, lack of child care, and fear. Managing these threats required scaling up capacity among the existing health workforce and mobilizing and recruiting additional health workers to address new tasks in prevention, secondary, and critical care.Reference Coates, Fuad and Hodgson 15 , Reference Williams, Maier and Scarpetti 16
At the onset of COVID-19, numerous countries mobilized to increase the number of health workers to meet the surging demand for HRH. Strategies to create surge capacity during the pandemic included augmenting staff numbers, redeploying personnel to areas of greatest need, utilizing telemedicine to enhance accessibility, and re-skilling and repurposing the workforce to ensure an adequate skill mix.Reference Williams, Maier and Scarpetti 16 –Reference Fleming, Thomas and Williams 21
In Bangladesh, existing legal frameworks and guidelines were activated to repurpose and redeploy frontline health workers, providing financial risk protection and incentives at the pandemic’s outset. Nepal initiated telemedicine-antenatal care during COVID-19, offering antenatal services to pregnant women via telephone consultations.Reference Sherchand 14 , Reference Bhattarai, Dhungana, Ensor and Shrestha 22 –Reference Thapaliya, Yadav and Bhattarai 24 Sri Lanka leveraged its military medical services to support the COVID-19 response, thereby relieving health workers and ensuring the continuity of routine immunizations and other primary health care services.Reference Gibson-Fall 25 –Reference Rannan-Eliya, Ghaffoor and Amarasinghe 27 Finding ways to increase the surge capacity and flexibility of human resources for health has been fundamental in responding to the pandemic.
This paper focuses on the surge capacity of HRH to evaluate how three health systems in South Asia managed staffing challenges during the COVID-19 pandemic. It specifically examines their ability to rapidly adapt staffing and implement systemic changes that facilitate staffing responses. The goal is to inform health system policies for managing surge capacity in an equitable and sustainable manner. The analysis covers the impact of COVID-19 on the health workforce from 2018 to 2021, based on a conceptual framework of surge capacity that will be elaborated upon in the paper.
To our knowledge, this is the first comparative study among the selected countries that examines HRH changes pre- and post-COVID-19. Additionally, there is a notable gap in the literature regarding a systematic framework for understanding surge capacity in health workforce crises. This study aims to propose a comprehensive framework for understanding the elements of surge capacity for HRH, illustrated through the experiences of Bangladesh, Nepal, and Sri Lanka during the pandemic. Quantitative data on HRH trends for physicians, nurses, and midwives during COVID-19 in these three countries will serve as a backdrop. Despite various contributions addressing specific elements, a unifying conceptual framework for HRH surge capacity does not exist in the published literature.Reference Watson, Rudge and Coker 1 –Reference Thomasian, Madad and Hick 5
Data and Methods
The study employed a mixed-methods approach, integrating both qualitative and quantitative methodologies to provide a comprehensive understanding of the surge capacity of human resources for health during the COVID-19 pandemic in Bangladesh, Nepal, and Sri Lanka.
Qualitative Methods
For the exploratory qualitative component, the investigators convened multiple times to spell out implicit theories and working hypotheses regarding the impact of surge conditions on human resources. These shared theories were shaped by the understanding that surging is a longitudinal process, necessitating actions before, during, and after a crisis. This insight prompted the investigators to seek participants whose involvement encompassed all phases of the crisis. Consequently, they developed an interview guide that comprehensively addressed each phase of the surge process.
The positionality of the research team was noted at the outset as one that included a physician who was practicing in a large Sri Lankan hospital throughout the pandemic, a human resources professional who was consulting on estimates of Bangladesh’s human resources reporting system, and health systems researchers from South Korea and USA. The professional backgrounds and surge experiences of subjects to be interviewed were carefully chosen, and then category-wise interviews were conducted in each country (Table 1). The inclusion criteria included having at least 10 years of experience, being willing to participate, and playing an important role in the delivery/ administration/ guiding the management as well as promotion/prevention of the disease during the crisis.
Table 1. Numbers of interviews in each country by type of participant
The interview guide was created by conducting a literature search on the subject; only materials relevant to the current investigation were taken into account. The following questions were in the interview guide: 1) What were the major staffing challenges during the COVID pandemic? 2) What cadres experienced the greatest reductions in staffing? 3) What types of operations and services were most affected? 4) What changes in work patterns occurred because of staffing limitations? 5) What strategies were used to retain and recruit staff during this period?
In Bangladesh, the Key Informant Interviews (KIIs) were carried out over the phone (5 cases) and also in-person (10 cases). In Nepal, all KIIs were carried out over video teleconference. Informal interviews were conducted by videoconference, in person, and by phone. Participants included physicians, nurses, administrators, and public health experts in each country as shown in Table 1. Interviews were conducted in English, Bangladeshi, and Sinhalese based on each subject’s preference. Because of the multiple languages, the interviews were not recorded for transcription, and instead, the interviewer took extensive written notes during each interview and shared these English notes with the whole team afterward.
The Johns Hopkins Bloomberg School of Public Health’s Committee for Human Research policy is that interview research confined to questions about an organization or community is not human subjects research and is therefore exempt from review. For the purpose of the data collection from Bangladesh, ethical consideration was taken from Pothikrit Institute of Health Studies (PIHS) in Bangladesh. The interview research was exempt from review in Sri Lanka and Nepal.
The analysis of the interviews was based on grounded theory by Strauss and Corbin.Reference Strauss, Corbin, Denzin and Lincoln 28 The study team met several times to discuss the interview results and iteratively identified the themes that were emerging as five elements of the conceptual framework. Investigators compared the elements from the interviews with past literature on surge capacity and achieved consensus on the final conceptual framework which was then applied to the quantitative data.
Quantitative Methods
Data sources
The numbers of human resources for health, particularly medical doctors and nurses and midwifery, were extracted from the WHO Global Health Observatory (GHO) data repository. We collected GHO data starting from 2018 to offer a 2-year baseline prior to the start of pandemic surge, which started in winter and spring of 2020. For validation of the WHO GHO dataset, secondary sources were collected where data were available. For instance, in Bangladesh, reports such as the Health Bulletin, Health Labor Market Analysis, Assessment of Healthcare Providers, and the Management Information System (MIS) database of Government of Bangladesh were used for comparison. In Sri Lanka, we validated the GHO data by comparing staffing trends from GHO to those observed in Kandy National Hospital (NHK), which is the second largest public hospital in the country. We were able to examine aggregated NHK administrative staffing records after obtaining the administrative clearance. Please see the supplementary material for the secondary sources.
Data analysis
To complement the qualitative analysis, it was essential to understand the quantitative changes in national health workforce counts before and during the pandemic in Nepal, Bangladesh, and Sri Lanka. We define the pre-pandemic period as 2018 and 2019 and cover data from the pandemic period, 2020 and 2021. This study employs quantitative methods to measure changes in staffing during the pandemic. It is important to note that the quantitative analysis presented here is meant to support the qualitative findings and enrich the overall conclusions of the paper. The data consists only of descriptive statistics, intended to provide context and illustrate trends, rather than to serve as a rigorous statistical method bringing new evidence. Specifically, the quantitative analysis involved a straightforward calculation of trends over time in total staffing and staffing per capita for doctors and nurses for each of the 4 years of data. This approach helps to visualize changes and support the qualitative insights with empirical data.
Results
Results From Qualitative Data
Interviews showed a prevailing theme: COVID-19 significantly strained the health care workforce. Informal discussions across all three countries highlighted severe preexisting staff shortages, which were further aggravated by the pandemic. This resulted in heightened burnout, exhaustion, and trauma among health care workers, along with alarming rates of infection, mortality, and excessive financial hardships.Reference Gupta, Dhamija, Patil and Chaudhari 29 , 30 The interviews also disclosed a lack of funding dedicated to HRH capacity, poor data systems, and lack of coordination to effectively task shift, repurpose, and redeploy HRH staff. To mitigate COVID-19’s exacerbating effect on HRH demands, the selected countries initiated measures to augment the health care workforce supply—strategies that can be systematically assessed using the proposed framework.
Interview participants described room for improvement in anticipation and preparedness—noting especially that early in 2020, there were shortages of ventilators, ICU beds, masks, and gloves. Furthermore, logistical challenges related to accommodations for health care workers and disruptions in transportation were evident. Doctors (Box 1), nurses, and a senior administrator (Box 2) in Bangladesh expressed deep concerns about their workplace safety and security.
Box 1. Quote from a physician
“We didn’t get PP, mask and other associated items in time during the Covid-19 pandemic. We also faced trouble in transportation, it was very difficult to get a public transport, as very few transports were available at that time. Furthermore, when we called the rickshaw puller or any other driver to go to a hospital, they became scared of us"
Box 2. Quote from an administrator
“During the Covid-19 pandemic, doctors and nurses faced life-threatening situations due to lack of proper protection. They had to run with insufficient supplies of PP, mask and other related materials. Health center authority was placing requisition continuously but we couldn’t supply adequately and timely. Also, we couldn’t ensure their accommodation and transportation properly”
The preexisting and persistent staff shortages across all three countries suggested that planners and health care workers could anticipate a crisis whenever demand surged. In response to the impending challenges posed by COVID-19, the government of Bangladesh proactively anticipated the needs of its health workforce and hospitals. A key initiative was the appointment of a focal person for each laboratory, tasked with coordinating sample collection and ensuring timely delivery of reports, which were communicated via mobile messages.
To bolster its health care workforce, the government of Bangladesh also secured financing to recruit human resources for health by securing allocations from development partners such as the World Bank, Asian Development Bank, and Global Fund. This enabled the recruitment of nearly 6000 doctors in 2020–2021, approximately 15,000 nurses between 2020 and 2022, and around 3000 technologists and technicians from 2019 to 2021. Additionally, a significant number of virologists and volunteers were mobilized under the Ministry of Health during the pandemic. Similarly, in Nepal, the Ministry of Health created thousands of new sanctioned positions, with 80% of the financing reallocated from other government sectors such as agriculture, transport, and infrastructure. Notably, Nepal’s government health budget saw a significant increase during 2020–2021, rising from 4.5–5% to 10% of the total government expenditure. Both Nepal and Bangladesh introduced telemedicine services by recruiting retired doctors to provide care for both COVID-19 and non-COVID-19 patients at the height of the pandemic.Reference Koirala and Parajuli 31 , Reference Khan, Rahman and AnjumIslam 32
Introducing on-site COVID-19 testing for both staff and patients was perceived as a crucial step in retaining health care workers by assuring them of safer working conditions. This initiative alleviated some concerns about occupational risks. Additionally, the idea of offering a risk premium as a supplemental pay was considered. In 2020, Bangladesh announced a financial benefit for health workers engaged in COVID-19 duties. However, interview participants indicated that the amounts provided were not substantial. An administrator and a health expert in Bangladesh echoed similar sentiments regarding staff retention efforts (Box 3).
Box 3. Quote from an administrator and a health expert
“Although the government of Bangladesh declared risk allowance or financial benefit for performing duty in health center during COVID-19, but that was not sufficient or regular. Even though no staff reduction, no staff left the govt services due to Covid-19 pandemic, as govt service in Bangladesh is much more secured compared to other job types”
The primary reason workers remained in their government positions was the perceived job stability during a time of great uncertainty. In Sri Lanka, the Kandy National Hospital (NHK), one of the country’s largest public hospitals, managed to retain its frontline health workers by offering risk allowances, financial benefits, and paid leave.
In response to the pandemic, Bangladesh also adapted by establishing COVID-dedicated hospitals and implementing innovative health system management policies. An administrator highlighted the duty roster policy for doctors and nurses during this period, which played a key role in managing the crisis (Box 4).
Box 4. Quote from an administrator
"Considering the practical situation, we introduced different type of roaster schedule for doctors/ nurses. Due to HRH shortage, doctors/ nurses were placed in shifting duty for a couple of days in line (ie. for 7days), then after a time period of isolation they are permitted to return back to home for a longer period. This policy was taken into consideration for the safety of service providers as well as for the safety of their family members. We allowed the aged or chronically ill doctors to provide services online”
Bangladesh mandated the conversion of several private hospitals into COVID-19 treatment centers during periods of peak caseloads. Telemedicine played a pivotal role in managing the increased workload, particularly in Sri Lanka, where these services were predominantly staffed by older health care workers and those with chronic conditions, reducing their risk of severe outcomes if they contracted COVID-19. In Nepal, specialized training programs for critical care doctors and nurses were introduced, facilitating task-shifting during the pandemic. At the height of the crisis, temporary hospitals and clinics were rapidly established, with unused health facilities, such as dermatological wards, repurposed to meet the surging demand. Community buildings and schools were also converted into quarantine centers. In Sri Lanka, a significant number of nurses were redeployed to intensive care units to bolster the response to the pandemic.Reference Rattray, McCallum, Hull and Ramsay 33
All three countries highlighted the concerted efforts by governments and health facilities to sustain, strengthen, and manage human resources for health to better prepare for and respond to crises. In Bangladesh, new HR policies now include provisions for task-shifting within hiring plans. Additionally, changes to the educational curricula for health professionals are underway, aiming to equip future generations of nurses and physicians with the skills and adaptability needed to respond effectively in times of crisis.
Results From Quantitative Data
Overall HRH levels and trends
Human resources for health generally showed an increase for all three countries including Bangladesh, Nepal, and Sri Lanka from 2018 to 2021. Figure 1 demonstrates the HRH trends by staffing categories (physicians and nurses/midwives) in absolute terms, per capita, and annual percentage changes. Bangladesh showed the greatest increases among the three countries in staffing post-COVID-19 with approximately 12.5 percent increases compared to pre-COVID levels. Nepal increased their HRH staffing during the COVID-19 crisis, although it had a slower growth (on average of 3.3 percent from 2020 to 2021) compared to pre-COVID-19 levels (7.4 percent). Sri Lanka also expanded its capacity in 2020 (9.2 percent) although decreased (-1.1 percent) its health workforce in 2021 compared to 2020. Nepal had the largest per capita number of medical doctors, nurses, and midwifery personnel, at 43.5 per 10,000 in 2021, followed by Sri Lanka at 36.3 and Bangladesh at 12.8.
Figure 1. Trends of HRH in Bangladesh, Nepal, and Sri Lanka from 2018 to 2021 (absolute and per capita terms, and annual changes).
Source: WHO Global Health Observatory (GHO) 2023.
Changes by HRH cadre
The overall trends toward increasing health workforce were investigated further by examining the per capita numbers of physicians and nurses/midwives. Variations among staffing types over time are shown for the selected countries (Figure 2). In Bangladesh, although the annual percent increases of doctors per capita decreased over time during COVID-19 from 9 percent in 2019 to 2 percent in 2021, annual percent changes for nurses per capita increased by 25 percent in 2020 compared to 2019 and increased further in 2021 by 27 percent compared to 2020. Nepal, however, had a slower growth for both doctors per capita (9 percent annual growth in 2019 to 2 percent in 2021) and nurses (7 percent annual growth in 2019 and 1 percent in 2020) compared to pre-COVID-19 levels. Similarly, in Sri Lanka, annual growth significantly slowed down for doctors from 15 percent growth in 2019 to -2 percent in 2021. For nurses in Sri Lanka, although 11 percent annual increases were shown in 2020 from 2019, slight decreases in nurses per capita were observed in 2021. In addition, as shown in Figure 3, Bangladesh had a greater proportion of doctors as a share of to the total HRH (physicians, nurses, and midwives). The average over 4 years in Bangladesh is 58 (percent) compared to Nepal (20 percent) and Sri Lanka (33 percent) as shown in Figure 3.
Figure 2. Proportions of medical doctors compared to nursing and midwifery in Bangladesh, Nepal, and Sri Lanka from 2018 to 2022.
Source: WHO Global Health Observatory (GHO) 2023.
Figure 3. Conceptual framework of HRH surge capacity: Anticipate, Recruit, Retain, Adapt, Sustain (ARRAS).
Source: Original conceptual framework of authors.
Triangulating the trend data
We cross-checked the WHO data on HRH by examining alternative sources. In Bangladesh, data from the Directorate General of Health Services indicated that the number of doctors and nurses increased between 2019 and 2021. Similarly, in Sri Lanka, the growth in the number of nurses and doctors on staff at the National Hospital of Kandy (NHK) aligned with the trends presented in the WHO data shown in Figures 2 and 3. However, our attempt to estimate national trends in health worker staffing in Nepal by reweighting the Demographic and Health Surveys Service Provider Assessment (SPA) data for 2015 and 2021 was unsuccessful due to changes in the coding of government clinic categories between the two surveys. For further details, the Supplement includes the data used for cross-checking.
ARRAS conceptual framework
Drawing on insights from qualitative interviews, complemented by existing literature on pre-crisis and intra-crisis HRH surge capacity,Reference Watson, Rudge and Coker 1 , Reference Bonnett, Peery and Cantrill 2 , Reference Hick, Barbera and Kelen 4 , Reference Coates, Fuad and Hodgson 15 , Reference Buchan, Williams and Zapata 18 we developed a novel conceptual framework (Figure 3). This framework integrates five key themes identified through our research: Anticipation, Recruitment, Retention, Adaptation, and Support.Reference Watson, Rudge and Coker 1 , Reference Bonnett, Peery and Cantrill 2 , Reference Hick, Barbera and Kelen 4 , Reference Coates, Fuad and Hodgson 15 , Reference Buchan, Williams and Zapata 18 , Reference Chambers, Quirk, MacIntyre and Bodkin 34 –Reference Runkle, Brock-Martin and Karmaus 39 These themes provide a comprehensive structure for understanding and enhancing HRH surge capacity during crises. These areas are not arranged hierarchically but are instead interconnected, with each influencing the others. The framework is rigorously aligned with our literature review and qualitative findings, ensuring a holistic approach to HRH management in crisis contexts. The interdependence of these thematic areas means that progress or challenges in one can significantly impact the effectiveness of others.
“Anticipation” refers to planning the number of human resources needed in each cadre based on numbers of mild, moderate, severe, and critical patients per day. It involves setting up reserves and cross-trained workers to allow task shifting and planning ways to finance these requirements.Reference Klein, Cheng and Lii 40 , Reference Rodriguez-Manzano, Chia and Yeo 41 These preparations each facilitate, but do not guarantee success. “Recruitment” and “retention” refers to strategies to expand health workforce capacity and incentivize health workers to respond to the crisis with a combination of financial rewards, psychosocial support, and adequate equipment and training. 42 , Reference Humphries, Creese and Byrne 43 “Adaptation” refers to meeting the heightened demand by repurposing and redeploying the existing health workforce. Measures include changing working patterns, bringing retired health professionals, calling on volunteers, and mobilizing nongovernmental and private sector workforce capacity.Reference Williams, Maier and Scarpetti 16 , Reference Zapata, Buchan and Azzopardi-Muscat 44 “Sustain” refers to efforts to strengthen the skills of the workforce through training, and building resilience through team building efforts that foster collaboration across different professions and professional units to ensure sustainability of crisis response based on prior personal relationships.Reference Burau, Falkenbach and Neri 45
Discussion
The COVID-19 pandemic tested the limits of health systems worldwide, forcing countries to adapt rapidly to unprecedented challenges. This study highlights how Bangladesh, Nepal, and Sri Lanka managed to maintain and expand their health workforce capacity and summarizes surge capacity through the ARRAS framework: Anticipate, Recruit, Retain, Adapt, Sustain. The lessons learned from these countries provide valuable insights into building resilient health systems capable of withstanding future crises.
Quantitative data documented a significant upward trend in the health workforce in Bangladesh, Sri Lanka, and Nepal both before and after the COVID-19 pandemic. Trend analysis showed average workforce increases of 12.5% in Bangladesh, 4.0% in Sri Lanka, and 3.3% in Nepal. Notably, Bangladesh and Sri Lanka expanded their HRH capacities considerably at the pandemic’s peak. In contrast, Nepal experienced slower growth, with its annual increase dropping to 2% in 2020 from 7.4% in the previous year. Interview data provided qualitative insights into the strategies employed by these countries for HRH surge capacity and post-pandemic workforce management. The ARRAS framework (Anticipate, Recruit, Retain, Adapt, Sustain) emerged as a unifying conceptual model for understanding these strategies.
Both qualitative and quantitative data aligned with a unifying conceptual framework for human resource surges in demand. The quantitative data indicated that 2020 was not an exceptional year in a prior trend of increasing numbers of doctors and nurses in each country. None of the countries demonstrated the ability to suddenly increase their overall health workforce numbers during the pandemic. This highlights the need for robust, long-term strategies to enhance surge capacity and ensure health systems are better prepared for future crises.
Our qualitative findings from the selected countries highlighted the critical roles of “Anticipate and Adapt” within the ARRAS framework. These countries established reserves and planned for task shifting and redeploying health workers to intensive care units in anticipation of surging demand. To address the increased demands on the health workforce, they implemented “Recruit and Retain” strategies along with supportive measures to bolster the supply of health workers and stabilize HRH capacity. These regular HRH increases were achieved despite higher occupational hazards of infection and the exhausting patient care demands placed on health workers.Reference Bourgeault, Maier and Dieleman 19 , Reference Gupta, Dhamija, Patil and Chaudhari 29 In addition, Bangladesh, Sri Lanka, and Nepal faced persistent challenges due to low funding dedicated to surge capacity and inadequate data systems for monitoring and evaluating HRH capacity at disaggregated levels. Nevertheless, during the pandemic, these countries managed to reallocate government funds from other sectors to enable HRH hiring, thereby filling public sector posts that were created on a temporary basis.
Another area of “anticipation” was the preexisting relationships between government sectors and between the government and the private health care sector. These relationships proved invaluable for better coordination during the crisis. For example, connections between ministries of health and schools for health professionals facilitated the establishment of reserves of medical students and the rapid deployment of training courses in contact tracing, surveillance, and vaccine administration. Additionally, collaborations between ministry officials and lawmakers supported the development of emerging financing and crisis response legislation and action plans.
Long-term strategies included expanding the scope of practice for nurses and allied health professionals and rethinking professional roles to facilitate task shifting for future crises.Reference Bourgeault, Maier and Dieleman 46 –Reference Buchan and Calman 48 The recent experiences in utilizing telemedicine technology and digital tools to enhance access and improve the productivity of care delivery can also be integrated into daily health care processes post-crisis.Reference Huang and Farboudi Jahromi 49 –Reference Schilirò 52 These measures collectively illustrate the importance of strategic anticipation, adaptation, and coordination in managing health workforce surge capacity effectively.
The study has several limitations. First, our analysis was restricted to data on doctors, nurses, and midwives due to constraints in the WHO Global Health Observatory dataset. Second, the WHO data from medical and nursing councils does not fully account for whether each registered doctor or nurse remains actively practicing in their respective countries. Third, the qualitative analysis relied on key informant interviews in multiple languages that were not audio-recorded and transcribed, but documented instead with handwritten notes. Although this approach was sufficient for illustrating the utility of the ARRAS framework, it does not provide definitive evidence that the framework comprehensively accounts for how these health systems managed staffing surges. Future research could reveal gaps or omissions in the framework.
Conclusion
The ability to sustain increased human resources for health during a crisis is a critical component of surge capacity and will be key to responding to future crises. The COVID-19 pandemic underscored the importance of a robust surge capacity, particularly in countries like Bangladesh, Nepal, and Sri Lanka, which regularly face challenges such as health workforce shortages, skill-mix imbalances, and inequitable distribution. Despite the preexisting inadequacies in HRH, these South Asian countries demonstrated significant adaptability and resilience in managing the surge in demand during the pandemic. Strategies included augmenting staff numbers, redeploying personnel, utilizing telemedicine, and re-skilling the workforce. These measures were facilitated by the activation of legal frameworks, financial protections, and strategic partnerships.
The study identified the ARRAS framework—Anticipate, Recruit, Retain, Adapt, and Sustain—which is essential for managing HRH surge capacity. Anticipation involved pre-crisis planning and setting up reserves. Recruitment and retention were achieved through financial incentives and psychosocial support. Adaptation included repurposing existing health facilities and utilizing digital tools. Sustainability efforts focused on long-term strategies such as expanding the scope of practice for health professionals and integrating telemedicine. However, the pandemic also highlighted significant gaps, including inadequate funding, poor data systems, and a lack of coordination. Addressing these challenges requires robust, long-term strategies to enhance surge capacity and ensure health systems are better prepared for future crises. The findings from this study provide valuable insights into HRH surge capacity and highlight the need for ongoing efforts to strengthen health systems. By learning from the experiences of Bangladesh, Nepal, and Sri Lanka, other countries can better prepare for future health emergencies and ensure a more resilient and responsive health workforce.
Open access
