The framework shifts the focus beyond the current monitoring of access to and contact with a health worker – i.e. skilled attendance at birth, or density of health professionals per 1000 population – and turns the AAAQ dimensions of the workforce into the key determining factors of the quality of care,23 represented in Fig. 1 as the “effective coverage gap”.
We apply the four workforce dimensions to guide a process-tracing analysis of HRH policy actions since 1990. Process tracing is an analytical tool for exploring causal mechanisms and contributory steps in the chain of events that collectively support a desired outcome.24–26 We collated historical data (Fig. 2, Fig. 3, Fig. 4 and Fig. 5) on national trends in the number of skilled birth attendants (midwives, nurses and physicians) employed in the public sector. Subject to data availability, the figures also show the rates for maternal mortality, under-five mortality and either infant or neonatal mortality. We have disaggregated the national policy and governance steps on HRH by their respective AAAQ dimensions (Table 2).27 The respective policies are captured chronologically to explore their linkages to national trends in the health workforce and maternal, neonatal and child health outcomes.