Develop an internal memorandum, create a workflow analysis flow chart

Scenario

Healthy Dynamics is a corporate wellness company that provides a broad range of wellness services for clients seeking to improve the health and wellbeing of their employees. One of the clients of Healthy Dynamics is not happy with their employee wellness program participation rates. Healthy Dynamics is not meeting the contract requirements of 60% engagement, resulting in lost revenue for the company and no return on investment (ROI) for the client. According to the contractual agreement, Healthy Dynamics must pay back the client $200,000,000 if the annual participation percentage is not met. Currently the client’s wellness program includes financial incentives for the employees if they complete the following wellness offerings (health assessment, biometric screening, and telephonic health coaching). The Healthy Dynamics CEO is now foreseeing a need to offer other healthcare services. The CEO has asked the Account Manager to create a business plan focused on increasing revenue and identifying risk that might negatively impact their continued relationship with the client. The Account Manager has tasked you, the Strategic Planning Manager, with preparing an internal memo to present to the CEO and to communicate to your internal team what you are envisioning as a desired future focus area to increase the bottom line for Healthy Dynamics and improve current and future client satisfaction rates.

Instructions

Develop an internal memorandum that includes:

A detailed description defining the differences between business planning and strategic planning in healthcare.
Identify a specific focus area in the healthcare industry that could increase revenue.
Create key questions that you will need to address in the development of your strategic plan for your focus area.

Create a workflow analysis flow chart that includes:

A list of healthcare leadership team members (e.g., CEO, Strategic Planning Manager, Account Manager, Marketing Manager, Project Manager, Financial Analyst, etc.,)
A comprehensive analysis of each team member’s roles and responsibilities in the development of the strategic plan.
Your assignment should include a title page, a reference page, and a minimum of three scholarly sources, two of which must be retrieved from the Rasmussen Library (See attached and choice 2 articles).

Rubric:

-Detailed description defining the differences between business planning and strategic planning in healthcare in a well-written internal memorandum.

-Clearly identified a specific focus area in the healthcare industry that could increase revenue in a well-written internal memorandum.

-Created detailed questions needed to address the development of a strategic plan in a well-written internal memorandum.

-Created a comprehensive list of healthcare leadership team members in the workflow analysis flow chart.

-Created a comprehensive analysis of each team member’s roles and responsibilities in the development of the strategic plan.

-Used and identified three or more credible sources in the memorandum.

https://doi.org/10.11613/BM.2019.020601 Biochem Med (Zagreb) 2019;29(2):020601

Abstract

The Balanced Scorecard (BSC) is a tool for strategic management that is used in many companies and organizations worldwide, both in the public
and private sector. With this purpose it has also been used in healthcare organizations and institutions but there are not many studies on the imple-
mentation of BSC methodology in the day-to-day clinical laboratory. This review shows the strategy for the development of a BSC, which includes
theoretical perspective objectives, as well as some indicators and goals with which the monitoring and quantitative measurement of the achieve-
ments of a strategic plan in a clinical laboratory can be done. Moreover, the results of the indicators allow the prioritization of the initiatives to be
implemented each year.
The methodology for the development of the proposed BSC includes the following steps: definition of theoretical objectives of each of the perspec-
tives most used in the management of a clinical laboratory (customers, financial, internal processes and learning) taking into account the vision and
the organizational model of the laboratory; creation of a strategic map of perspective objectives; definition of the relevant indicators to follow up on
the objectives in a quantitative manner and establishment of the goals. Whether or not the laboratory is a reference laboratory, in which specific and
infrequent analysis and health population programs are performed, is another fact to take into account. In this review a BSC for a reference clinical
laboratory of the Spanish public sector is shown.
Keywords: balanced scorecard; clinical laboratory; management; strategic plan

Received: November 21, 2018 Accepted: February 27, 2019

A balanced scorecard for assessing a strategic plan in a clinical laboratory

Luisa Alvarez*1, Anna Soler1, Leonor Guiñón1, Aurea Mira2

1Quality Unit, Biomedical Diagnostic Center, Hospital Clínic, Barcelona, Spain
2Managing Director, Biomedical Diagnostic Center, Hospital Clínic, Barcelona, Spain

*Corresponding author: [email protected]

Short review

Introduction

Many organizations still present the results ob-
tained from the application of a strategic plan as a
list of achievements reached, sometimes accom-
panied by budget compliance but without using
any other type of analysis, which includes the
study of the impact of their results on the whole.
In this regard, a tool that can be used to track and
obtain quantitative data of the degree of achieve-
ment of the strategic plan’s objectives is the Bal-
anced Scorecard (BSC). The BSC is one of the most
popular performance management tools, which
categorizes the quantifiable objectives of an or-
ganization into four perspectives: financial, cus-
tomer, learning and internal processes (1). For each

objective, indicators and their goals are defined in
order to provide objective and quantitative infor-
mation about the achievements. It was introduced
by Kaplan and Norton in the 1990 and, although it
was originally used in industry, over time its use
has been extended to applications beyond that of
strategic management in this field (2,3). Shortly af-
ter its creation it was introduced for the measure-
ment of performance in healthcare organizations
and institutions in the USA, Canada and in Europe
(4-9). Although the BSC was applied as a tool for
strategic management in laboratory analysis as
early as 2003, few studies have been developed
since then (10). Among them there are those of

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

Salinas, that use indicators of the laboratory pro-
cesses classified according to the four perspectives
cited and of Salas which orders the indicators ac-
cording to the perspective of the internal process
(11-13). It is worth highlighting this shortage of
studies in Spain, despite the fact that in 2008, the
Spanish Society of Laboratory Medicine (SEQCML)
defined Recommendations for the development
of a BSC in the clinical laboratory (14). Moreover,
there are no studies on the implementation of its
use to assess results of the application of a BSC for
monitoring long-term strategic plans.

Given that the BSC’s usefulness for evaluating a
strategic plan in hospital management has been
shown, we hypothesized that the BSC would pro-
vide a useful tool for the Managing Board of clini-
cal laboratories, both to describe the vision and
strategy of their laboratories and to manage im-
plementation and assess the achievements of a
four-year strategic plan. Thus, the aim of this re-
view is to show the strategy that should be fol-
lowed for the development of a BSC, which in-
cludes perspective objectives as well as the indica-
tors and goals with which the monitoring and
quantitative control of the achievements can be
carried out, in the short and long-term of a strate-
gic plan.

Strategy for the development of the BSC

The Managing Board has to take into account the
vision of the clinical laboratory and the manage-
ment model of the organizational structure when
designing a BSC.

The strategy to use includes the following steps:

1. Definition of theoretical perspective objec-
tives

These objectives arise from the answers to the
questions that are formulated considering the four
main perspectives that exist in the management
of a laboratory’s activity:

Customer perspective: How to increase the value
with which customers perceive our activity? What
are their needs and expectations? As some au-
thors have indicated, health institutions have to
devote the greatest efforts to this perspective,

since they are the ultimate recipients of the ac-
tions of improvement and the objectives defined
in all perspectives (8,15). Recipients of the activity
of the clinical laboratory are: citizens, patients and
clinical physicians of the hospital. Furthermore, in
the case of a reference clinical laboratory, physi-
cians or users of other laboratories who send sam-
ples for analysis should be included. As well, in
some clinical laboratories the Ministry of Health of
a country’s Government, that commissions the
laboratory population health programs, will be in-
corporated.

Among the objectives to take into account in this
perspective is the improvement of patient safety
in order to prevent patients from potential risks in
all phases of the analytical process, as Plebani has
shown (16). On the other hand, the clinical labora-
tories that have implemented the ISO 15189 stand-
ard, from the 2012 version have to demonstrate
that they are managing the risks that can affect
patient safety (17).

Financial perspective: How should providers of
financial resources perceive us? How should the
clinical laboratory achieve additional incomes to
those of the Ministry of Health of a country’s Gov-
ernment? Taking into account the comments in
the customer perspective, in healthcare organiza-
tions the objectives of this perspective should go
after those of the customer’s perspective, as indi-
cated by Kaplan and Norton.

Internal process perspective: In which processes
should laboratory staff focus their efforts on and
be excellent in satisfying their customers? Can an
increase in efficacy and efficiency in these pro-
cesses be shown?

Learning perspective: How to achieve a greater
involvement of staff that encourages greater effi-
ciency, higher quality and more innovation? It is an
established fact that in all organizations it is neces-
sary to manage the human factor to a high stand-
ard. Both the one that occupies strategic positions
and the one directly in charge of performing the
analysis, since this factor is what the organization
is based on and that which allows the organization
to achieve excellence. Professionals appreciate the
fact that the Managing Board of a clinical labora-

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

tory is concerned with satisfying all those require-
ments that impact the work environment. There-
fore, a large number of the objectives of the learn-
ing perspective must be aimed at enhancing the
acquisition of greater skills for the personnel and
their professional development, and improving
their motivation and increasing satisfaction.

Finally, the objectives of the strategic plan are in-
cluded in the theoretical perspective’s objectives.
At this point, it has to be mentioned that real ob-
jectives of the strategic plan can have very differ-
ent scopes, particularly in clinical laboratories that
include the activity of all specialties. In such clini-
cal laboratories it can be observed, on the one
hand, that some of the objectives of the strategic
plan (i.e. “extension of existing technologies and
procedures for biomedical diagnosis”) may be in-
cluded in a single perspective (i.e. internal pro-
cess), but is carried out in all Departments. On the
other hand, other objectives of the strategic plan
(i.e. “reorganization of a department”) may be di-
rected to a single department, but initiatives to
achieve the objective may be included in all per-
spectives.

2. Design of the strategic map of the perspec-
tive’s objectives.

The map is developed analysing the cause-effect
relationships of the different objectives among
them. It represents, in graphic form, how the ob-
jectives are linked within their perspective, and
also their relationships between the four perspec-
tives, constituting what is called the alignment of
the objectives. This alignment helps the coher-
ence between them to be understood and shows
how the achievement of some objectives leads to
the achievement of others in the form of a cas-
cade. This strategic map begins with the human
factor, in terms of learning objectives, and then fi-
nally develops into the customer objectives.

3. Definition of indicators and goals of the
perspective’s objectives.

In order to monitor the perspective objectives, rel-
evant indicators and goals have to be designed
which will allow the results obtained to be dis-
played in a quantitative manner. In this regard, it
should be noted that the results of some indica-

tors may assess more than one objective, whether
or not it belongs to the same perspective. Moreo-
ver, in defining the indicators, the organizational
characteristics of the clinical laboratory (if it has
autonomy of management or a system of promo-
tion of professionals, among others) and its type (if
it is a reference clinical laboratory or not) have to
be taken into account. For better management in-
dicators should show, in a clear and understanda-
ble way, to the whole organization the contribu-
tion of the initiatives defined each year in the
achievement of the strategic plan.

The results of the indicators, defined in the cus-
tomer perspective, have to measure the intangible
aspects of the organization as those that demon-
strate the capacity of its professionals to advise
any client or user when they performs a consulta-
tion. As well as, they must show the ability of the
clinical laboratory’s Managing Board to respond to
complaints and incidents that may arise from lab-
oratory performance. In the case of a reference
clinical laboratory, indicators should communicate
the ability to make the laboratory into a leader
based on the excellence of its activity.

One important aspect to consider is the fact that
the results of the objective’s indicators of the BSC’s
financial perspective must be able to demonstrate,
to the entire organization, the leadership capacity
of the clinical laboratory’s Managing Board to
achieve budget compliance. Moreover, the ability
to generate sufficient self-financing will enable
them, on the one hand, to invest in those techno-
logical resources necessary for a better service to
citizens and, on the other hand, to increase the
training of all its professionals.

On the basis of the results obtained, indicators
from the internal process perspective have to
demonstrate the improvement of diagnostic and
analytical process efficiency. Results of these indi-
cators can also demonstrate the greater efficacy of
the analytical process that must be reflected in a
better compliance with the turnaround time and
in obtaining higher quality results. In a reference
clinical laboratory it should also show its capacity
to innovate laboratory medicine.

The results of the learning perspective’s indicators,
in conjunction with those from the perspective of

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

internal processes, must allow the Managing
Board to know at all times the dedication it has,
both to overcome the resistance to change, and to
increase the professional competence of person-
nel in responding to new orientations that the
clinical laboratory will incorporate.

Once the BSC is designed, it is important to inform
the laboratory professionals of the objectives de-
fined. Moreover, as the first results of the indica-
tors are obtained, they must be shown to these
professionals, with values that clearly demonstrate
both their degree of participation and the achieve-
ments derived from their activity. This will syner-
gistically orient their capacity and efforts with
those of the Managing Board in order to obtain
the achievements of the clinical laboratory.

Application of the BSC to assess the four
year strategic plan in a reference clinical
laboratory

The organizational structure of the clinical labora-
tory located in Catalonia (Spain) includes the De-
partments of the different specialties of the labo-
ratory (Pathology, Clinical Biochemistry, Haematol-
ogy, Immunology and Microbiology). In addition
to these Departments, there are two Operational
Areas where automated activity is performed,

both in equipment for analysis based on molecu-
lar absorption spectrophotometry and in immu-
nological techniques (Core Laboratory), as well as
in equipment for carrying out studies based on
molecular biology (Core Molecular Biology). It also
has six transversal support units: client manage-
ment, quality, economic-administrative manage-
ment area, teaching, research and information sys-
tems coordination. The activity performed in the
clinical laboratory each year, more than 7.000,000
determinations or diagnostic studies from a cata-
logue of more than 2800 tests, is carried out by
430 professionals. It is also a reference center for
almost 300 laboratories in Spain which send their
specialised tests to perform. Moreover, in this clini-
cal laboratory different population programs are
carried out, such as newborn screening in the de-
tection of congenital conditions, prenatal screen-
ing tests, histocompatibility studies for solid or-
gan and stem cell transplantation (e.g. HLA typing
and viral serologies for all organ transplants) and
program for early detection of colorectal cancer in
Catalonia.

It has to be stated that the elaboration of a BSC
was facilitated because laboratories have imple-
mented quality management systems (both ISO
9001 and ISO 15189), which allow the Managing
Board of the clinical laboratory to acquire greater

Perspective Objectives

Customers

1. To increase customer satisfaction

2. To improve the image and prestige of the laboratory

3. To improve patient safety

4. To meet the health needs and expectations of the population

Financial
1. Compliance with the strategic budget

2. Generation of sufficient self-financing to meet the objectives of the laboratory mission

Internal Process

1. To innovate laboratory medicine

2. To improve the diagnostic and process efficiency

3. To improve the quality and efficacy of the process and product

Learning

1. To motivate the personnel

2. To increase the training of strategic personnel

3. To increase staff competence

4. To increase internal communication

Table 1. Perspective objectives

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Figure 1. Strategic map of perspective objectives

knowledge of the organization and its context.
Moreover, the Managing Board uses the annual re-
view report of the quality management system to
know about the improvement actions that are
needed to be implemented, as well as the annual
initiatives that are required (18).

The perspective objectives established for this
clinical laboratory, whose vision is to lead labora-
tory medicine generating and integrating new
knowledge and technological changes and be rec-
ognized as a clinical laboratory of excellence, are
shown in Table 1. In these theoretical objectives,
the annual initiatives defined to achieve the objec-

tives of the four-year strategic plan are classified.
The strategic plan of the laboratory was elaborat-
ed taking into account the guidelines of the Man-
aging Board of the Hospital. Moreover, there is an
alignment between both strategic plans whose
priority areas are: patients (the reason of being of
the Hospital); professionals (their engine) and re-
sources (which make continuity and innovation
possible in care).

In Figure 1 the relationship between the objec-
tives of the same perspective and the relationships
of the objectives between the four perspectives
are shown.

To meet the health
needs and

expectations of the
population

To improve
patient safety

To improve the image
and prestige of the

laboratory

To increase
customer

satisfaction

Generation of
sufficient self-financing
to meet the objectives

of the laboratory
mission

Compliance with
the strategic budget

To improve the
diagnostic and

process efficiency

To improve the
quality and efficacy
of the process and

product

To innovate
laboratory
medicine

To increase
internal

communication

To increase the
training of strategic

personnel
To increase

staff
competence

To motivate
the personnel

Financial perspective: economic
type objectives

Learning perspective: objectives for
the improvement of the human factor

Internal process perspective:
objectives for the improvement
of the efficacy, efficiency and
quality of processes and products

Customer perspective:
objectives representing the
value provided to customer

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

Objectives Indicators Goals

Customer perspective

1. To increase customer satisfaction Degree of satisfaction internal and external customers (assessment of
treatment, reliability of results and overall evaluation)

NSI > 75

Number of complaints received from users ≤ 12 / year

2. To improve the image and
prestige of the laboratory

Degree of external client satisfaction for the advice received in case of
consultation

NSI > 75

Number of publications in scientific journals with impact factor ≥ previous year

3. To improve patient safety Number of incidents reported by Hospital staff due to laboratory performance ≤ previous year

Percentage of turnaround time compliance > 95%

4. To meet the health needs and
expectations of the population

Percentage of population programs that are carried out in the laboratory ≥ previous year

Percentage of tests included in catalogue addressed to the oncological
patient in relation to all the incorporated tests

≥ 10%

Financial perspective

1. Compliance with the strategic
budget

Percentage of deviation of the budget in consumables material,
personnel and total budget

0 – 1%

2. Generation of sufficient
self-financing to meet the objectives
of the laboratory mission

Annual variation in the number of patients and requests received in the
laboratory

0 – 1%

Annual variation in the billing to external clients 0 – 1%

Customer loyalty: the percentage variation of billing to clients who
requested analysis to the laboratory in the last two years

> 10%

Annual variation in the number of clients: percentage of new clients and
percentage of lost clients

0 – 5%

Internal process perspective

1. To innovate laboratory medicine Percentage of tests incorporated in the Catalog in response to new areas
of knowledge in relation to all incorporated tests

> 10%

2. To improve the diagnostic and
process efficiency

Percentage of tests incorporated to increase the diagnostic efficiency
thanks to technological development of the total test incorporated

> 10%

3. To improve the quality and
efficacy of the process and product

Percentage of determinations with defaults that do not meet the
turnaround time every month of the year

< 3%

Percentage of results of external quality assurance programs to be
reviewed according to the criteria of the organizer

< 3.5%

Percentage of annual initiatives achieved > 80%

Learning perspective

1. To motivate the personnel Degree of professional satisfaction (the assessment of actions dedicated
to improve their quality of life and human and professional promotion)

NSI > 75

Percentage of personnel who have improved their professional category > 10% triannual

Percentage of absenteeism < 2%

2. To increase the training of
strategic personnel

Number of training activities aimed at professionals who carry out
strategic activities

> 1 / year

3. To increase staff competence Percentage of specific training activities to increase professional competence > 10%

Percentage of technicians in a laboratory who can develop the same
activity with respect to the total number of technicians

> 20%

4. To increase internal communication Number of actions carried out to increase the internal communication > 3 / year

NSI – normalized satisfaction index. An NSI between 75 and 85 reflects a good valuation and more than 85 an excellent valuation.

Table 2. Indicators and goals of the customer perspective objectives

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The indicators and goals of the objectives of each
perspective are shown in Table 2.

Furthermore, that indicators have to be defined
taking into account the objectives and goals of the
Government of the country. In this way, since 2005
in Catalonia, patient safety is one of the main pri-
orities of the Ministry of Health of the Govern-
ment’s objectives. So, in the proposed BSC those
aspects in which the performance of the clinical
laboratory can give rise to incidents in other points
of the Hospital, or those caused by the delay in the
delivery of a result or a diagnostic study, are espe-
cially assessed.

As it can be seen in Table 2, some of the goal’s val-
ues are expressed as NSI (Normalized Satisfaction
Index) which is obtained from a calculation devel-
oped by International Business Machines Corpora-
tion (IBM) that is based on the penalty of the low-
est scores.

NSI = [(Ax0) + (Bx25) + (Cx50)
+ (Dx75) + (Ex100)] / N

Where: A = number of responses with a satisfac-
tion score of 1 (very bad), B = number of responses
with a satisfaction score of 2 (bad), C = number of
responses with a satisfaction score of 3 (regular), D
= number of responses with a satisfaction score of
4 (good), E = number of responses with a satisfac-
tion score of 5 (very good) and N = A + B + C + D + E.

The organizational structure of this reference clini-
cal laboratory, that it is based on management au-
tonomy, allows the Managing Board to promote,
on the one hand, efficiency in the management of
human and technological resources and, on the
other, the dedication of resources to special tests,
which are in development or that are not request-
ed frequently. That is why the objectives of the
strategic plan and its annual initiatives are aimed
at implementing the most cutting-edge services
using the latest technology. Sometimes this in-
cludes the use of the latest large equipment which
allows the automated generation of a large num-
ber of results, or the use of innovative technolo-
gies not generally implemented in the network of
healthcare clinical laboratories. It is important to
note that the results of the indicators of the finan-
cial perspective allow the efficiency of the clinical

laboratory in the budget management approved
by the Hospital Managing Board to be demon-
strated, both in the costs of consumables and
equipment, as well as personnel. Likewise, the
greater efficacy of all internal processes, especially
the strategic planning of the organization and per-
sonnel management processes, will be shown in
the achievement of a larger number of the initia-
tives defined annually.

Furthermore, in this reference clinical laboratory, it
is important to consider the results of the learning
perspective indicator, “Percentage of professionals
who have improved their professional category”,
because they will reflect the effort made by all the
laboratory’s personnel to maintain and improve
their competence and their participatory and col-
laborative spirit.

Concluding remarks

A comprehensive BSC that includes theoretical ob-
jectives for each perspective, as well as indicators
and the goals to be achieved, can be a valid, man-
ageable and simple tool in the clinical laboratory
to monitor and quantitatively measure the degree
of achievement of the objectives of a strategic
plan in those organizations that, due to their com-
plexity, have numerous objectives and each year
define a large number of very different initiatives.

This model of BSC has the particularity of having the-
oretical objectives of perspectives rather than the
original strategic objectives. It is adaptable to any or-
ganizational model and to the resources available.
Yet, like all BSCs, its use allows us to demonstrate the
laboratory’s strategy in carrying out its mission.

The BSC is a useful tool to demonstrate to the hos-
pital Managing Board the effectiveness of the clin-
ical laboratory’s managing board and profession-
als both in achieving the initiatives defined annu-
ally, as well as in the development of the strategic
plan. Moreover, it also shows how it can fulfil its
capacity to generate self-financing that allows it to
carry out initiatives of greater risk oriented to cus-
tomers. The annual results of the indicators allow
us to identify in which perspectives the efforts
have to be prioritized.

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

Acknowledgments

We thank the Managing Board and all profession-
als of the clinical laboratory for their work and val-
uable contribution.

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Potential conflict of interest

None declared.

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aking countries. MAR 2003;31:361-87.

10. Gumbus A, Lussier RN. Developing and using a balanced
scorecard: a case study with SWOT analysis. Clin Leadersh
Manag Rev. 2003;17:69-74.

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Toward a New Strategic Public Health
Science for Policy, Practice, Impact,
and Health Equity
Rebecca Bunnell, PhD, MEd, Juliet Ryan, MPH, Charlotte Kent, PhD, and the CDC Office of Science and
CDC Excellence in Science Committee

other high-level documents.

• Specified structures in the field of medical ethics in the country and the possibility of the
formation of new structures based on the emerging needs.

• Educating and training the ethics professionals and promoting the presence of the graduates in
medical ethics-related fields.

• Availability of scientific resources related to medical ethics.
• Availability of guidelines and codes on issues related to medical ethics.
• Possibility of studying in medical ethics-related fields.
• Possibility of centralized policy-making in the field of medical ethics.

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• Lack of transparency in the national macro-management policies in the field of medical ethics and
instability of the administratorship in the related fields.

• Lack of a coherent theoretical Islamic–Iranian framework to address medical ethics issues in practice.
• Limited access to basic and applied research and updated original Iranian-Islamic literature in medical

ethics.

• Lack of communication, interdisciplinary, inter-sectoral cooperation, and interaction, particularly between
the universities and the Islamic seminaries.

• Inadequate numbers of medical ethics experts and uncertainty of their position in the organizational chart
of the healthcare system.

• Insufficient access to the international scientific resources and communications in the related fields.
• Unavailability of the necessary resources to support medical ethics research.
• Weakness of the educational content and implementation processes of medical ethics educational

curriculums.

• Ignoring the professional ethical capability in recruiting, the assessment, and promotion of the learners,
faculty members, and providers of health services.

• Lack of appropriate and consistent rules, regulations, and bylaws about several issues of medical ethics.
• Lack of efficient system for monitoring and surveillance of medical ethics.
• Absence of an institutional mechanism for ethical appraisal of policies, rules, and regulations in the health

system.

• Absence of nationwide structures and national, provincial, and organizational ethics committees in areas
other than research, e.g., the absence of national committees of clinical ethics and ethics in medical

education.

• Weaknesses in the management of medical ethics research to direct them towards solving ethical problems
of the healthcare system.

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• Emphasis of the Supreme leader on theorizing in the field of humanities, knowledge-producing, and
discourse based on ethical-spiritual values.

• Numerous areas for research in the field of medical ethics.
• Islamic-Iranian noble resources of knowledge related to medical ethics.
• Growing demand for the ethical improvement of education and research among the scientific and medical

community as well as the stakeholders.

• Support of the high-level national documents, including the constitution, development plans, and national
comprehensive scientific map, for ethical development.

• Researchers interested in medical ethics.
• Religious beliefs, inner conscious, unconscious ethical, and common cultural, ethical, or moral beliefs

among the society.

• Active related intellectual fields such as jurisprudence, philosophy, sociology, etc.
• Potential stakeholders’ desire to enter this field.
• Research and educational institutes in medical universities that are active in the field of medical ethics.

T
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• The negative influence of the public ethics issues on professional medical ethics.
• Reduced public trust in the medical community.
• Reduced motivation of healthcare community to work effectively due to the socio-economic conditions.
• Insufficient justification of the stakeholders of medical ethics discourse and lack of common language

among the clergy, doctors, lawyers, philosophers, and other stakeholders.

• Governance of technical-empirical paradigm (worldview) over the humanities worldview in the country.
• Growing tendency to use the medical methods and devices for non-medical purposes
• Lack of sufficient sensitivity to vulnerable groups including migrants, refugees, and slumdogs.
• Lack of public awareness and misunderstanding of medical ethics debates.
• Wrong and restrictive perception of laws and regulations affecting the implementation of medical ethics.
• Lack of the explanation of the consistency between the Islamic and Iranian medical ethics with the

predominant secular discourse of medical ethics.

• Uncontrolled and unmannered use of the social networks by students.
• Giving the power to enhance commercial, technological, and industrial aspects of medical professions.

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Table 3- The main goals of the national strategic plan for medical ethics in Iran.

Goal 1
To attain the basic Islamic-Iranian framework based on the heritage of medical

ethics regarding the related contemporary knowledge.

Goal 2
To assemble a national collection of documents stating the approved standards of

medical ethics.

Goal 3
To achieve and implement policies, structures, and specific resources in the field of

medical ethics.

Goal 4 To obtain the support and involvement of the key stakeholders of medical ethics.

Goal 5 Development of research in the field of medical ethics.

Goal 6 Development of education in medical ethics.

Goal 7
Developing effective national and international communications in the field of

medical ethics.

Goal 8 Establishment of a comprehensive system of action plans in the field of medical ethics

The first goal emphasizes shifting the

medical professionals’ attention towards the

great heritage of Islamic-Iranian knowledge.

Four objectives were defined in this regard,

as follows:

• Assembling, translating, classifying, and

publishing the Islamic texts related to

medical ethics.

• Collecting, translating, and critical

evaluation of the contemporary knowledge

of medical ethics.

• Strengthening the conceptualization and

interdisciplinary dialogue in the field of

medical ethics.

• Compiling the textbooks related to medical

ethics.

To pursue the goal and its related objectives,

the 19 defined activities included compiling

comprehensive textbooks for the students of

different fields of study (general medicine,

nursing, dentistry, pharmacy, etc.) and at

various education levels. Development of

the “Islamic Medical Ethics Encyclopedia”

and other reference books are also among

these activities.

The second goal aims to provide necessary

national documents, codes, guidelines, and

regulations related to medical ethics as

indicated in table 3. This is to be fulfilled

through the following objectives:

• Development of an appropriate mechanism

for the required assessment of ethical

standards (laws, regulations, and guidelines

related to medical ethics).

• Supporting the development of ethical

standards (laws, regulations, and guidelines

related to medical ethics).

• Design and implementation of appropriate

mechanisms for the approval and

legitimization of ethical standards (laws,

regulations, and guidelines related to

medical ethics).

To achieve these objectives, 35 activities

were designed in a detailed and complete

way. These activities included the

“Establishment of a committee to identify

the gaps in legislation and required ethical

guidelines in healthcare and drafting the

suggested regulations and ethical

guidelines”. Compiling ethical codes and

guidelines for the dentistry, pharmacy,

reproductive health, assisted technologies,

organ transplantation, end of life care,

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emergency medicine, the care of vulnerable

groups, the care of patients with mental

illness, healthcare in disasters, the use of

biobanks, collected health data, the

transmission of biologic samples to foreign

countries, etc.

Goal 3 focuses on achieving and

implementing policies, organizational

structures, and resources in the field of

medical ethics through the following five

objectives:

• Creating the necessary organizational and

administrative structures for healthcare

institutions.

• Providing required financial and human

resources for the healthcare institutions.

• Considering ethical enclosures in all

policies, laws, and regulations related to

healthcare.

• Ethical surveillance and monitoring of all

the healthcare-related policies and

regulations.

• Revising the health system regulations and

laws based on ethical approaches and

concepts.

The establishment of the national committee

for clinical ethics and related secretariat

office in the MOHME are among 18

activities set to achieve this goal and its

associated objectives. Forming the

departments of medical ethics in the major

organizations such as the “Iranian Medical

Council” and the “Nursing Organization of

the Islamic Republic of Iran” and providing

the checklists and regulations for ethical

appraisal of the pharmacies, the drug

companies, medical professionals, faculties,

fellows, residents, and students in the field

of healthcare are among these activities.

Likewise, the allocation of specific funds to

support the educational, research, and

executive affairs of medical ethics by the

MOHME is one of the activities related to

the third goal.

Involvement of the main stakeholders in the

field of medical ethics and attracting their

support and contribution have been

following through the objectives of the

fourth goal as outlined below:

• Developing appropriate strategies for

disseminating information to the key

stakeholders including the general public

and patients.

• Creating appropriate mechanisms for

surveillance and obtaining feedback from

key stakeholders including the public and

patients.

• Providing a supportive environment for the

stakeholders’ engagement and their support.

• To support founding non-governmental

organizations (NGOs) in the field of medical

ethics and encourage the existing health-

related NGOs to focus on the issues of

medical ethics and patient rights.

Activities defined for materializing the goal

include teaching general concepts of

bioethics, patients’ rights in high schools

and compiling age-appropriate books for the

children and adolescents to familiarize them

with the ethics-related issues.

Six objectives are defined for the fifth goal

that targets expanding research in the field

of medical ethics. The objectives include:

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• Development of necessary strategies for

the needs assessment and priority-setting for

research in the field of medical ethics.

• Supporting research in the field of medical

ethics in all related healthcare sciences.

• Backing the production of evidence-based

science in the field of medical ethics.

• Supporting the publication of the scientific

literature and improving the quality of the

existing journals.

• Provision of the infrastructure needed by

medical ethics researchers to access

international resources.

• Providing required funds for essential

research projects and national initiatives in

the field of medical ethics.

Moreover, the foundation of the medical

ethics research centers in the leading

universities of the country, integrating

medical ethics departments within the

structure of specialized medical research

centers, creating and supporting related

journals, holding medical ethics conferences,

post-doctorate, sabbatical courses, and

providing comprehensive databases of

medical ethics studies and researchers are

among 11 activities defined for fulfilling the

fifth goal.

Goal 6 focuses on education emphasizing

the following objectives:

• Qualitative and quantitative improvement

in the relevant academic courses on medical

ethics as well as expanding the

interdisciplinary postgraduate programs.

• Forging regional, and international,

scientific, and educational collaborations

with prominent universities by supporting

the student and faculty exchange programs.

• Improving the quality of medical ethics

education provided to the learners in

different disciplines at various levels.

• Integration of medical ethics education into

the curriculum of all medical and health-

related disciplines.

• Providing and offering medical ethics and

professional ethics education in the form of

in-service programs and continuing medical

education (CME) courses for the healthcare

system personnel.

The change of the pedagogical methods in

medical ethics from the traditional lectures

to the interactive methods such as small

group discussion, workshops, case reports,

launching dual degree doctorates

(MD/Ph.D.), MD/MPH programs,

fellowships, and short-term courses in

clinical ethics and research ethics are among

13 activities listed under the sixth goal.

The seventh goal aims to promote

collaborative activities in the country or

around the globe and consists of four

objectives, as follows:

• to establish a national medical ethics

network with the participation of all main

stakeholders.

• To support organizing national, regional,

and international conferences on medical

ethics.

• To provide Iranian researchers with the

opportunity to participate in regional and

international conferences.

• To develop international collaborations and

partnerships with the universities and

institutions scientifically active in the field

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of medical ethics.

To achieve these objectives, twelve activities

including the establishment of a regional

medical ethics forum in the Eastern

Mediterranean Region, founding the Islamic

Medical Ethics Forum within the Islamic

countries, facilitating membership in

regional and international organizations

related to medical ethics, and signing

agreements for scientific cooperation with

national and international universities have

been considered.

Four objectives shed more light on the

operational planning of medical ethics as the

8th goal:

• Establishing future studies and a

surveillance system for medical ethics in the

fields of education, research, and service

delivery.

• Establishing a system for monitoring,

evaluation, and providing feedback for

medical ethics in the fields of education,

research, and service delivery.

• Integrating the descriptive and analytical

data and findings in the field of medical

ethics.

• Establishing a rating, accreditation system,

and encouraging ethical features in the

healthcare system.

The main related activities are consisted of

developing a framework for the national

reports in the field of medical ethics,

compiling annual reports of “medical ethics

strategic planning program”, “ethics in

medical sciences research”, “monitoring of

medical ethics education”, “observing

patients’ rights and the status of the medical

professionals’ rights”, “evaluating justice in

health care”, “analysis of complaints

received by the MOHME, the Iranian Legal

Medicine Organization (LMO), and the

Medical Council of the Islamic Republic of

Iran”

Discussion

The historical documents confirm the

Iranian physicians’ interests in ethical

conduct in their practice for centuries (9,

10), under the influence of the rich culture

and the religious principles of

Zoroastrianism and Islam (11). Despite

facing various difficulties in the recent

decades (12), substantial scientific progress

has been made in the field of medical ethics

in the country (13).

After the compilation of the first national

strategic plan of medical ethics in 2002 (4),

policymakers, related organizations,

faculties, and researchers were responsible

for its implementation. Key stakeholders

approved the vision and mission of the plan

and were committed to achieving its goals. It

is worth mentioning that in the current

strategic plan, the specified stakeholders

consisted of seven groups as follows:

1. International stakeholders (such as UN

agencies, regional scientific organizations,

associations, universities, and research

centers, especially in the Islamic world).

2. Decision-making and policy-making

bodies including the Parliament, High

Council of the Cultural Revolution, the

Guardian Council, and the MOHME.

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3. Governing and executive bodies including

the MOHME, several related ministries,

Iranian Legal Medicine Organization, Red

Crescent Society, regulatory authorities, and

medical universities.

4. Clients (Patients, their relatives, and the

whole community).

5. Unions and Professional Organizations

(the Medical Council and the Nursing

Council of the Islamic Republic of Iran).

6. Service providers (including Hospitals,

clinics, health care providers, insurance

companies, and pharmaceutical or medical

equipment companies).

7. Professional stakeholders (educational

departments and instructors in the field of

medical ethics at the universities and the

religious seminaries, research centers related

to the field of medical ethics, postgraduate

students, and faculties).

The process of design and development of

the current strategic plan was led by the

AMS, a high-level independent scientific

authority in the country. This is considered

as an advantage and opportunity to generate

the plan through the consensus of several

stakeholders and reinforce their

responsibilities for achieving future goals. It

is so important that the AMS set timelines

and monitor the progress of the plan towards

the goals. Moreover, reviewing the plan

would be carried out regularly.

All the key stakeholders are expected to be

fully engaged in the implementation of the

plan, commit time and efforts to venture out

and accomplish the objectives. Despite the

consensus on the defined goals and

activities, there may be controversies on the

priority rankings of the action plan and

surveillance strategies.

The World Medical Association (WMA)

adopted a 5-year (2020-2025) strategic plan3

in 2019, the main purpose of which was to

promote international standards in medical

ethics. “Medical Ethics”, “Universal Health

Coverage”, “Human Rights and Health”,

and “Organizational Capacity” are four

main strategic priorities. Promoting the

international code of medical ethics along

with global discussion to provide a new

revision of the international code of ethics in

2022, governance development, member

integration, and staff development are

among the priorities and deliverables.

The Emory Center for Ethics (Atlanta,

Georgia, US) has been a leader in several

fields of ethics since 1990, creating the first

5-year strategic plan in 2011. The “Vision”

of the second strategic plan (2016-2021) is

“to inspire and advance scholarship and

education in ethics, to ignite the moral

imagination of leaders in all walks of life,

and to foster lives of moral meaning and

ethical engagement”.4 Key strategic priority

areas of the Center consist of:

– Ethical engagement through scholarship

– Ethical engagement in health and science

– Ethical engagement through corporate

partnerships

– Ethical engagement through citizenship and

the public good

– Ethical engagement in education

3. www.wma.net/wp-content/uploads/2020/02/2020-

2025-Strategic-plan-1.pdf

4.http://ethics.emory.edu/about_the_center/CFE%20Strat

egic%20Plan%202016%202021%20FINAL.pdf

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– Ethical engagement in Arts

– Ethical engagement through financial

stability

For each strategic priority, some initiatives

and their metrics are determined. For

example, academic books and peer-reviewed

journal articles are two initiatives of “Ethical

Engagement through Scholarship”. As for

“Ethical Engagement in Education”, some

initiatives such as developing ethics

curriculum and courses (undergraduate,

graduate, doctoral) and non-degree

educational offerings are defined. Defining

metrics for each initiative plays an

encouraging role in engaging the faculties

and the members in related studies.

Kirigia et al have reviewed and discussed

the current status as the way forward to the

establishment of the national health research

systems in 47 countries of the World Health

Organization (WHO) African Region (14).

Although “Research for Health” was the

subject of their study, their strategies and

recommendations are used in other fields as

well as for strengthening medical ethics

discourse. Several key contributing factors

emphasized by Kirigia et al include (14):

– An official national health policy and

strategic plan

– Related legislation components

– Appropriate coordination mechanisms

– Regulation mechanisms for scientific and

ethical review committees at national and

institutional levels and in hospitals and

clinics

– Developed collaborative agreements

– Creating and sustaining resources

– Financing and health budgetary planning

– Securing funding by the private sector and

local and international NGOs

– Promotion and implementation of research

– Facilitating the production of human

resources and strengthening their

competencies through design and

implementation of master and Ph.D. courses,

bursaries, and training grants

– Building or reinforcing necessary

infrastructures, such as well-equipped

offices and laboratories

All identified factors that enable national

health research systems are critical for the

establishment and reinforcement of the

national medical ethics plans. Fortunately, it

seems that the eight goals of our strategic

plan cover all emphasized factors stated by

Kirigia et al (14).

The national strategic plan working group

has approved 60 activities including

compiling books and educational resources,

ethical guidelines, related codes, and

regulations. It has also endorsed 60

recommendations to MOHME to provide the

required infrastructure and empower the

healthcare professionals. Table 4

summarizes the key activities carried out in

recent years, before and after compiling the

second strategic plan.

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Table 4- Summary of some key activities in recent years

Title/type Timeline
In accordance

with

Responsible

Organization(s)

General guideline for Professional

Codes of Ethics
2017 Goal 2

The Medical Council of

Islamic Republic of Iran

Revising National Guidelines for

Publication Ethics
2017 Goal 2,4,5 MOHME

Compiling a textbook as an

educational resource for medical

residents

2015-2020 /

in press
Goals 1,6

MEHRC, the Medical Ethics

Group of EMRI of TUMS

Evolution and Innovations packages in

Medical Education: 6th package:

Promotion of Professional Ethics

2015-2016 Goal 6 MOHME

Herbal Medicine Research Protocol 2015 Goal 2 MOHME

Hidden curriculums as longitudinal

themes for “medical ethics and law”

and “professionalism”

ongoing Goal 6
TUMS, and a few other

designated universities

The Charter of Rights for clients in

Medical diagnostics Laboratories
2012 Goal 2

High Council of Medical

Ethics of MOHME

The code of Ethics for National

Pharmaceutical System
2012 Goal 2

MEHRC, High Council of

Medical Ethics of MOHME

The National Code of Ethics for

Nurses
2009-2011 Goal 2

The Medical Ethics Group

of EMRI of TUMS, MEHRC,

MOHME

Enhancing specific publications such

as journals in the field of medical

ethics; including the Journal of

Medical Ethics and History of

Medicine

ongoing Goal 1

MOHME, Ethics research

centers and universities of

medical sciences

Annual Medical ethics Congress/

And Training workshops and courses

2013- up to

now /

ongoing

Goals 3,4,6,7

MOHME, MEHRC, AMS,

TUMS and other

Universities of Medical

Sciences, etc.

Defining an educational package to

promote medical ethics and

professionalism

2016-

now/ongoing
Goal 6 MOHME

Evaluating teaching medical ethics in

all medical universities
2018-2019 Goal 6 MOHME

To plan and execute the proposed activities

to achieve the goals, several tasks are in

progress. As an example, the development of

the Iranian Code of Medical Ethics (ICOM)

to determine the ethical codes of mutual

behaviors in the provision of medical

services are being pursued by the MEHRC

at the Tehran University of Medical Sciences

in collaboration with the AMS. The ICOM

has been on the agenda with approximately

150 headings; 24 topics of which have

already been completed in the public

consultation phase. After summarizing and

incorporating the feedback from the

workshop participants, the codes were

published in Farsi (Persian Language) to

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seek the input of the healthcare academics

and practitioners. The final results are

reported in a recent report of AMS.5

Moreover, the promotion of ethical

standards and the development of related

guidelines have been high on the agenda

during recent years. For example, specific

national guidelines for palliative care in

terminal patients have been compiled by the

medical ethics department of the

“Endocrinology and Metabolism Research

Center of Endocrinology and Metabolism

Institute (EMRI)” of Tehran University of

Medical Sciences (TUMS) in 2017 due to

the ever-increasing attention to palliative

care in the country. This was supported by a

grant from the WHO office in the MOHME.

The results of the project6 were submitted to

the High Council of Medical Ethics of

MOHME and after approval (February

2019) was conveyed to the medical sciences

universities for being implemented in

clinical practice.

Education is an integral part of the current

strategic plan and has been the focus of

accrediting bodies. Although working in the

field of medical ethics requires lifelong

learning, the educational mission of ethics is

never accomplished. This is based on the

Henk ten Have stating (15) that the

empowerment of medical ethics education

has always been one of the main initiatives

around the globe. Accordingly, more than

5.http://www.ams.ac.ir/sites/default/files/book%20Akhl
agh%201400–02-18-021.pdf
6. Available (in Farsi) at:

http://nursing.fums.ac.ir/images/Palliative_Care_guidelin

es-Final_compressed.pdf

twenty projects including the development

of textbooks for different graduate and

undergraduate programs, ethical guidelines

for medical education, and ethical checklists

for health professionals have been proposed.

To achieve the educational goal of the new

strategic plan, we designed a national

descriptive survey to evaluate the medical

ethics education in medical sciences, which

is an ongoing project. Providing higher

academic education in the field of medical

ethics is also considered an educational

achievement in our country (5). The

bioethics graduates are now helping to

empower medical ethics discourse in the

research centers, clinics, and hospitals, to

provide specific education, ethics

consultations, and to lead ethics ground

rounds, and even to contribute to health

policymaking.

Conclusion

Academic knowledge and practice of

medical and research ethics have developed

enormously in recent decades. Compared

with the first strategic plan (4), we have

made great progress in strengthening and

flourishing medical ethics throughout the

country. However, considering the ethical

challenges ahead, it is evident that there is

no room for complacency.

The development of the medical ethics

strategic plan was an attempt to improve the

capacity of the health system to be more

proactive in client advocacy. Today, the

main challenges facing our healthcare

system include increasing moral sensitivity,

enhancing adherence to ethical principles

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amongst medical professionals and

promoting a positive ethical climate in the

system. It is also known that an acceptable

level of accountability of health

professionals is necessary to provide decent

standards of care in an ethical atmosphere.

We hope that achieving the goals and

objectives of the recent strategic plan would

play an essential role in the promotion of

professionalism among healthcare

practitioners in Iran. The strategic plan

presented in this article can also be adapted

for other contexts and environments, taking

into account the national priorities,

challenges, and shortcomings.

Acknowledgements

We would like to convey our sincere thanks

to workshop participants (in alphabetical

order): Dr. Forozan Akrami, Dr. Khalil

Alizadeh, Dr. Masoud Asadi, Dr. Omid

Asemani, Dr. Amin Asgharian, Dr. Morteza

Ashrafi, Dr. Hamidreza Ayatolahi, Dr. Sajad

Azmand, Dr. FattanehSadat Bathaie, Dr.

Shabnam Bazmi, Dr. Hasan Behboodi, Dr.

Saeed Beiroodian, Dr. Kourosh Delpasand,

Dr. Zeynnab Derakhshan, Dr. Sedighe

Ebrahimi, Dr. SeyedAli Enjoo, Dr. Mohsen

Fadavi, Prof. Dariyoosh Farhhod, Dr. Mina

Foroozandeh, Dr. Nazafarin Ghasemzadeh,

Dr. Sadat Hosseini, Dr. Nikzad Isazadeh, Dr

Maliheh Kadivar, Dr. Ali Khaji, Dr.

Mehrzad Kiani, Dr. Mansoureh Madani, Dr.

Alireza Milanifar, Dr Mina Mobasher, Dr.

SeyedHasan Moghadamnia, Dr. Maryam

Montazeri, Dr. FatemehSadat Nayeri, Dr.

Nasrin Nejadsarvari, Dr. Davood Nezam-

Eslami, Dr. Mahshad Nouroozi, Prof.

Mohammad Pajoohi, Dr. Mojtaba Parsa, Dr.

Roya Rashidpouraie, Dr. MohamadReza

Razaghi, Dr. Mohsen Rezaie-Adriani, Dr.

Mahbobeh Saber, Dr. Mehran Seyf, Dr.

Behzad Shams, Dr. MohammadNader

Sharifi, Prof. SeyedMahmood Tabatabaie,

Dr. Ladannaz Zahedi.. The special thanks go

to Dr. Pooneh Salari, Dr. Amir

Keshavarzian, and Dr. Leila Afshar for their

valuable input and contribution in compiling

this national plan. The authors also would

like to thank Dr. Reza Baradar Jalili and Dr.

Ali Tooti for the English editing of the

paper’s first draft. We have furthermore to

thank Ms. Firoozeh Hajipour for her sincere

cooperation.

Parsapour A., et al.

J Med Ethics Hist Med. 2021(December); 14: 17.

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Copyright of Journal of Medical Ethics & History of Medicine is the property of Tehran
University of Medical Sciences and its content may not be copied or emailed to multiple sites
or posted to a listserv without the copyright holder’s express written permission. However,
users may print, download, or email articles for individual use.

Cuschieri et al. Health Res Policy Sys (2021) 19:43
https://doi.org/10.1186/s12961-020-00665-y

R E S E A R C H

Mapping the burden of diabetes in five small
countries in Europe and setting the agenda
for health policy and strategic action
Sarah Cuschieri1, Elena Pallari2* , Natasa Terzic3, Ala’a Alkerwi4 and Árún Kristín Sigurðardóttir5,6

Abstract
Background: Diabetes is a global epidemic affecting every country. Small countries, however, face distinctive chal-
lenges related to their health system governance and their ability to implement effective health systems’ reforms.
The aim of this research was to perform a comparative assessment of existing diabetes management practices at the
population level and explore governmental-related policy for Cyprus, Iceland, Luxembourg, Malta and Montenegro.
This is the first time that such an evidence-based review study has been performed in the field of diabetes. The overall
purpose was to set the agenda for health policy and inform strategic actions for small countries that can benefit from
dealing with the diabetes epidemic at a country level.

Methods: We collected data and synthesized the evidence on dealing with diabetes for each of the five small Euro-
pean countries according to the (1) epidemiology of diabetes and other related metabolic abnormalities, (2) burden
of diabetes status and (3) diabetes registers and national plans. We collected data by contacting Ministry representa-
tives and other bodies in each state, and by searching through publicly available information from the respective
Ministry of Health website on strategies and policies.

Results: Diabetes rates were highest in Cyprus and Malta. National diabetes registers are present in Cyprus and Mon-
tenegro, while national diabetes plans and diabetes-specific strategies have been established in Cyprus, Malta and
Montenegro. These three countries also offer a free holistic healthcare service to their diabetes population.

Conclusions: Multistakeholder, national diabetes plans and public health strategies are important means to provide
direction on diabetes management and health service provision at the population level. However, political support
is not always present, as seen for Iceland. The absence of evidence-based strategies, lack of funding for conducting
regular health examination surveys, omission of monitoring practices and capacity scarcity are among the greatest
challenges faced by small countries to effectively measure health outcomes. Nevertheless, we identified means of
how these can be overcome. For example, the creation of public interdisciplinary repositories enables easily accessi-
ble data that can be used for health policy and strategic planning. Health policy-makers, funders and practitioners can
consider the use of regular health examination surveys and other tools to effectively manage diabetes at the popula-
tion level.

Keywords: Type 2 diabetes, Noncommunicable diseases, Healthcare systems, Health policy, Healthcare delivery,
Global burden of diseases, Small countries

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco
mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Open Access

*Correspondence: [email protected]
2 MRC Clinical Trials and Methodology Unit, University College London,
London, UK
Full list of author information is available at the end of the article

http://orcid.org/0000-0003-1967-6345

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

http://creativecommons.org/publicdomain/zero/1.0/

http://crossmark.crossref.org/dialog/?doi=10.1186/s12961-020-00665-y&domain=pdf

Page 2 of 10Cuschieri et al. Health Res Policy Sys (2021) 19:43

Key messages

• Most small member states have national diabetes
plans, national registers and strategies.

• Diabetes plans exist in Cyprus, Malta and Monte-
negro, countries that have relatively higher diabetes
prevalence rates and burden of disease compared to
the much lower diabetes burdens in Luxembourg and
Iceland.

• Regular health examination surveys are currently
missing and, as part of monitoring and evaluation,
this is something that should be considered.

Introduction
Noncommunicable diseases (NCDs) are global epidemics
that contribute to a substantial burden related to morbid-
ity, disability and premature death. Diabetes falls within
the top five predominating NCDs across the world,
including Europe [1]. In 2019, the International Diabe-
tes Federation (IDF) reported an estimated 463 million
adults (aged 20–79 years) suffering from diabetes world-
wide, with 59 million residing in Europe [2]. By 2045, a
15% rise in the diabetes population is expected to occur
within Europe [2].

With the global spread of the coronavirus disease 2019
(Covid-19) pandemic in 2020, several mitigation legis-
lations have been implemented by almost all countries
across the globe to safeguard the health and safety of
their populations. A number of these legislations have
an effect on the healthcare systems and previously estab-
lished services, including diabetes screening, prevention
and management [3]. Although it is too early to assess
the exact impact of this pandemic on the diabetes situa-
tion across Europe, it can be predicted that the relation-
ship between diabetes and the healthcare services can
only be negative in the near future, especially in light of
the observed relationship between diabetes and Covid-19
[3].

Small countries are known to face distinct challenges
related to their health system governance and their health
service delivery due to lack of capacity, limited resources,
small market size and their constrained ability to imple-
ment effective health system reforms [4]. However, this
is not always the case. Indeed, recently in the face of the
Covid-19 pandemic, the small country of Malta proved
to be a prototype for small and large European countries
alike in the response to the first wave of the pandemic
through health system preparedness and timely measures
[5].

Recently, a common path was agreed among the 11
Member States in the Small Countries Initiative of the

WHO European Region [6] to foster a collaborative
framework, to promote health and reduce health inequi-
ties. These goals were based on the alignment of priori-
ties on health policies within the European health policy
Health 2020 framework, the development of capacity-
building infrastructure to promote health and reduce
health inequities, the set-up of supportive and engag-
ing environments for the implementation of the goals
and the development of a platform to share learning and
experiences.

Considering the extend of the global diabetes epi-
demic, it was considered paramount to also explore
this epidemic from a small-country perspective, while
investigating how the associated population-level stra-
tegic planning can be improved. The World Bank and
the Commonwealth define small countries or states as
those with populations under 1.5 million. This defini-
tion together with data on the countries participating
in the COST Action CA18218–European Burden of
Disease Network (burden-eu) [7] allowed us to include
Cyprus, Iceland, Luxembourg, Malta and Montenegro
in this study. The objective of the study was to perform
a comparative assessment of the existing diabetes situa-
tion at the population level while assessing the particu-
lar country’s governmental-related policy among these
five small countries in Europe. The overall aim was to set
up an agenda for health policy and strategic action for
small countries in dealing with the diabetes epidemic at
a country level. More broadly, the goal is to contribute to
the overall continuous battle against the diabetes crisis by
identifying potential solutions for small countries.

Methods
Methodology rationale
The authors are members of the CA18218–European
Burden of Disease Network (burden-eu) CA18218 that
focusses on mapping the burden of disease at the Euro-
pean level. Our study was based on a simple model of
analysing the existing state of diabetes by synthesizing
the evidence to make relevant suggestions on disease
management and health policy for these countries. The
methodology is split into three parts.

The first part is concerned with the context of analys-
ing the five small European countries of Cyprus, Ice-
land, Luxembourg, Malta and Montenegro. The rationale
behind this selection is threefold. Firstly, there is a lack
of studies conducted at a national level in these countries
and, hence, this provides an appropriate opportunity to
study these. Secondly, when compared to other European
countries, these small countries have a high prevalence
of diabetes and, as such, it was considered appropriate to
focus on these countries to shed light on the problem at
hand and how it can be tackled. Thirdly, when comparing

Page 3 of 10Cuschieri et al. Health Res Policy Sys (2021) 19:43

small states, lessons can be learnt not only to help small
countries but also to inform actions and decisions in
geographically larger countries, with a more decentral-
ized decision-making system in place, or at a regional
level, having the same population size as that of an entire
small-country state.

The second part of this work involves the documenta-
tion of the health-policy status for each of the five small
European countries according to the (1) epidemiology of
diabetes and other related metabolic abnormalities, (2)
burden of diabetes status and (3) diabetes register and
national plans. Our proposed study aims to contribute
to the aforementioned effort within Health 2020 by iden-
tifying gaps, differences and similarities between these
countries towards evidence-based health-policy planning
and strategic action.

The third part of the study is focussed on the synthesis
of the findings of an evidence-based proposal on diabetes
management in the following three dimensions: (1) mon-
itoring and evaluation, which covers health examination
surveys and their implementation in the five countries;
(2) prevention, to draw on existing practices for public
health diagnostic and screening practices; and (3) health
system performance, to contextualize the impact of care
delivery on the disease burden for each population.

A summary of the methodology protocol can be seen
in Fig. 1.

Data sources
We collected data by contacting Ministry representa-
tives and other governmental bodies in each state, and
searched for publicly available information from web-
sites on strategies and policies as available at the respec-
tive Ministry of Health, some health sector divisions
and appropriate bodies, such as statistical organiza-
tions. We identified published articles originating from
national surveys and datasets conducted in each of the
five countries: Cyprus, Iceland, Luxembourg, Malta and
Montenegro. When data were not available online, we
contacted the corresponding person who would in turn
send us the available nonconfidential data. We searched
for documents on national strategies, action plans and/or
policies on NCDs and diabetes at a country level.

Data analysis
The burden of diabetes at a population level was evalu-
ated in terms of the “disability-adjusted life years”
(DALYs) metrics as reported by the Institute for Health
Metrics and Evaluation (IHME) in their Global Burden of
Disease (GBD) study [8]. The same resource was used to
evaluate each country’s profile characteristics [8]. Com-
parisons between the DALYs, years lived with disability
(YLDs) and years of life lost (YLLs) data were performed

for the five small countries, using the GBD Compare tool
[9]. DALYs is an overall measure of the disease burden
that takes into account the YLDs and the YLLs due to a
disease, which in this case is diabetes. The importance
of DALYs is that it provides a consistent, geographic and
time-bound metric of population health on both mor-
bidity (YLDs) and mortality (YLLs) measures in units of
years. The use of DALYs can assist in relative compari-
sons between countries for a specific condition to iden-
tify gaps in performance, research, health delivery or
policy to prevent illness, disability or premature death.
It can also be used to guide health system planning and
public health interventions within a country for different

Fig. 1 The research methodology

Page 4 of 10Cuschieri et al. Health Res Policy Sys (2021) 19:43

diseases or by tracking changes for a specific disease over
time. Epidemiological data were obtained from the lit-
erature in each of the five states for both incidence and
prevalence per 100,000 people.

The scientific literature was reviewed by the authors
and common frameworks were identified. The data
were categorized according to diabetes: prevalence
data, diabetes register, governmental strategy and pol-
icy and diabetes health care. Subsequently, the pub-
lished literature, strategies, policies and burden of
disease data were reviewed, and an agenda for policy
and strategy action based on the small countries expe-
rience was formulated.

Results
Table 1 shows the population characteristics of the five
small countries in Europe that were included in the
study according to the GBD study for 2017. Although
all five countries have comparable life expectancy,
intercountry variations are still observed. Cyprus

ranked the highest in terms of diabetes mortality at the
population level, followed by Montenegro and Malta.

Epidemiology of diabetes and other related metabolic
abnormalities
Diabetes prevalence rates varied across the five small
countries, with the highest rates being reported in Malta
and Cyprus followed by Montenegro (Table 2) [10–13].
However, it is worth noting that the data obtained from
surveys were conducted in different time frames as well
as following different study protocols. For example, Mon-
tenegro’s diabetes estimate was based on a combina-
tion of data obtained from a national register under the
patronage of the Institute of Public Health and the pri-
mary healthcare information system. A similar picture is
observed for the prevalence of obesity, where the high-
est obesity rates among the five small countries were
reported by Malta (Table 2) [12, 14–17]. Yet, data on
impaired glucose regulation (impaired glucose tolerance
or impaired fasting glucose) and the metabolic syndrome

Table 1 Distribution of the population characteristics among the five small countries in Europe, 2017 [6]

GDP Gross domestic product

Population characteristics Cyprus Iceland Luxembourg Malta Montenegro

Population 875.9 K 337.5 K 590.5 K 434.5 K 626.3 K

GDP per capital (in $US) 31,531 47,062 97,887 36,920 15,716

Life expectancy at birth (in years) 81.85 82.85 81.65 80.95 76.5

Diabetes death ranking at a population level 5th > 10th > 10th 8th 6th

Table 2 Comparisons between prevalence of the different metabolic abnormalities across the five small countries in Europe

BMI Body mass index

Prevalence Cyprus Iceland Luxembourg Malta Montenegro

Type 2 diabetes 10.4% (2005) 6.72% (2005–2011) 9.8% (2016–2018) 10.4% (2014–2016) 10.2% (2014)

Obesity (BMI > 30 kg/m2) 25.5% (2008) 26.6% (2017) 19.2% (2016–2018) 34.1% (2014–2016) 25% (2016)

Impaired glucose tolerance – – 25.6% (2013–2015) – –

Impaired fasting glucose – – – 24.3% (2014–2016) –

Metabolic syndrome – – 28.0% (2008–2009) 26.3% (2014–2016) –

Fig. 2 Comparative summary of the diabetes epidemiology and official diabetes registers and plans across the five small countries in Europe

Page 5 of 10Cuschieri et al. Health Res Policy Sys (2021) 19:43

was available only for Luxembourg and Malta (Table 2)
[18–23].

Diabetes register and national plans
Official national diabetes registers are only present in
Cyprus and Montenegro. Malta’s national diabetes reg-
ister is still in the pipeline. However, the Endocrinol-
ogy Department of Malta’s state hospital has an online
database that physicians can voluntarily input diabetes
patients’ data. This database can act as the foundation
for the construction of a national diabetes register [24].
National diabetes plans have only been established in
Cyprus, Malta and Montenegro [25, 26]. A compara-
tive summary of the official diabetes registers and plans
across the five small countries can be observed in Fig. 2.

Cyprus
In Cyprus, diabetes is high on the health policy agenda
due to its impact on the economy and productivity [25].
A national diabetes strategy (2016–2024) is in place and
it is based on five pillars: (1) prevention, (2) early detec-
tion and care, (3) rehabilitation, (4) diabetes registry and
(5) research. An interdisciplinary body, the National Dia-
betes Committee, has been appointed by the Ministerial
Board in order to execute the policy of this diabetes stra-
tegic plan. There are 12 institutions carrying out research
on diabetes on the island; the University of Nicosia, Nico-
sia General Hospital and the University of Cyprus are
among the top three. Although the island has are no clin-
ical practice guidelines, the specialists follow European
guidance or that of the UK. Cyprus has a high diabetes
prevalence, but the amount of research done in the field
is not appropriate to the needs of the population [27].

In Cyprus, individuals suffering from diabetes are enti-
tled to a holistic healthcare service that includes free
medication and consultations.

Iceland
In Iceland, the position of diabetes within the politi-
cal agenda is a delicate one. Existing national policies
target diabetes-related diseases and risk factors, includ-
ing obesity, overweight, physical inactivity, smoking
and unhealthy eating, but not prevention of diabetes. In
fact, there is no national plan for diabetes [25]. However,
individuals diagnosed with diabetes are eligible for free
medication with a minimal fee for check-up visits to dia-
betologists, diabetes nurses, ophthalmologists and podia-
trists. The diabetes care in Iceland follows the American
Diabetes Association guidelines [28]. An interdiscipli-
nary working group appointed by the Minister of Health
has recently suggested a national diabetes register for Ice-
land [29].

Luxembourg
In Luxembourg there is no diabetes-specific national
plan but rather a general national prevention policy that
targets the different chronic NCD risk factors, including
diabetes, obesity and overweight, dietary habits, smok-
ing, physical inactivity and the harmful use of alcohol [25,
30]. The “Eat Healthy and Move More 2018–2025 Action
Plan” is an interministerial prevention strategy developed
by the Education, Family, Sports and Health Ministries,
with the aim of promoting a healthy diet and physical
activity. Diabetic patients are eligible for free medica-
tion. However, there are no systematic yearly check-ups
organized with endocrinologists or other allied health
professionals. The patients need to organize follow-up
consultations on their own initiative. Those opting to
have check-up consultations will get a percentage reim-
bursement by the government for the incurred fee. In
addition, a national plan for 2019–2023 to fight cardi-
oneurovascular diseases is being implemented, with a
specific focus on diabetes risk.

Malta
In Malta, a national diabetes plan was set up entitled
“Diabetes: A National Public Health Priority: 2015–2020”
[31]. This plan complemented the already existing “Dia-
betes Shared Care Programme” [32]. This programme
follows a multidisciplinary team effort to provide a free
holistic care plan to the diabetes population and includes:
regular follow-ups with a diabetes nurse, diabetologist,
general practitioner with a special interest in diabetes,
dietician, ophthalmologist, ophthalmic nurse and podia-
trist. Furthermore, all individuals diagnosed with diabe-
tes are entitled to free medication as well as to a limited
amount of blood glucose monitoring strips every month.
Additionally, there are a number of preventive strategies
and action plans that target the different risk factors for
diabetes including the “Healthy Weight for Life Strategy”,
the “Noncommunicable Disease Control Strategy for
Malta” and the “Food and Nutrition Policy and Action
Plan for Malta”.

Montenegro
In Montenegro, a governmental “Strategy on Health-
care of People who Live with Diabetes 2016–2020” with
Action Plan 2017–2020 is under completion [26]. The
main objectives of this strategy are to improve the health
of these people through effective measures, including
early detection, control, treatment and prevention of
associated complications. A multisectoral approach is
in place to safeguard the adherence and maintenance of
this strategy. A national strategy for the prevention and
control of NCDs (2008–2020) is also set in place, includ-
ing the “Master Plan for Health System Development

Page 6 of 10Cuschieri et al. Health Res Policy Sys (2021) 19:43

(2015–2020)” focussing, among other things, on pri-
orities for diabetes. Montenegro has other strategies,
including the “National Strategy for Sustainable Devel-
opment—NSSD 2016–2030” and the “Strategy for
Healthcare Quality Improvement and Patient Safety
2019–2023”, with both strategies targeting NCDs. Indi-
viduals with diabetes are eligible for free medication and
healthcare services under the Compulsory Health Insur-
ance Act.

Burden of diabetes
On assessing the DALYs metric for the diabetes situation
across the five small countries in Europe, we draw on dif-
ferences and similarities, as shown in Table 3. Montene-
gro had the highest diabetes DALYs and YLDs for 2017
compared to the other small countries; however, Cyprus
had the highest YLLs for the same year.

Discussion
Diabetes is a growing epidemic that gives rise to several
different challenges and imposes a substantial burden
on healthcare services. This has led to a number of col-
laborative reports and joint actions between countries
and states that are members of the EU with the aim of
addressing this epidemic [33]. Across Europe, many
countries have introduced national diabetes plans or
NCD strategies as part of a national effort to contain this
epidemic. We identified a wealth of information related
to the strategies and action plans that are related to (1)
monitoring and evaluation aspects, (2) prevention and
(3) health system performance.

A multistakeholder approach is key when develop-
ing such strategies, in addition to a sustainable political
leadership [1, 34]. However, political support for a spe-
cific framework allocated only to diabetes is not always
in place, as seen Iceland, which has the highest gross
domestic product (GDP) of the five small states studied.

On the other hand, national diabetes plans are already
established in Cyprus, Malta and Montenegro. These lat-
ter three small countries have relatively higher diabetes
prevalence rates and burden of disease compared to a
much lower diabetes burden in Luxembourg and Iceland.
Nevertheless, all five small countries have an established
preventive strategy targeting the various diabetes risk
factors and NCDs.

Monitoring and evaluation
The key to successful NCD strategies is the continuous
monitoring and evaluation of the situation at a popula-
tion level [1]. This is maintained by undertaking regular
health surveys, ideally through health examination sur-
veys. Without regular updated evidence-based data,
there will be sparse evidence on whether the strate-
gies are working efficiently and whether there is a need
for more rigorous interventions. Conducting regular
health examination surveys is one of the many challenges
faced by most small countries due to the lack of human
resources and research budget allocation. In fact, over
the past 15 years, a national representative health exami-
nation survey covering diabetes was conducted only once
in Cyprus and Malta, never in Iceland and Montenegro,
while in Luxembourg health examination surveys were
performed on a regular basis (2007–2008, 2013–2015
and 2016–2017) [13, 35–37]. The European Health Inter-
view Survey consists of a number of health modules,
including a self-reported medical history of diabetes,
and is conducted every 5 years among the EU countries,
including Iceland [38]. This type of survey depends on
self-reporting; hence, it is prone to incorrect recall infor-
mation biases. However, it still constitutes a good source
of information on health indicators at the population
level, with reasonable resources.

Prevention: management plans and execution
An integrated approach is required when targeting
chronic diseases, including diabetes [39]. Prevention is
one of the key priorities in terms of reducing the burden
of diabetes within the population [1]. In fact, prevention
is one of the key pillars of the national diabetes plans
set up by Cyprus, Malta and Montenegro [31]. Regard-
less of this focus on prevention, it is of utmost impor-
tance that such strategies are adhered to and maintained.
Establishing multidisciplinary diabetes care protocols in
each country may be the way forward to ensure adher-
ence to such strategies. Nonetheless, it is paramount that
adequate human resources, infrastructure and financial
budget allocation are present to enhance the healthcare
services. In Montenegro, a multisectoral approach has
been established to ensure that the strategies are adhered
to. However, the implementation of these strategies still

Table 3 Distribution of the burden of disease metrics for
diabetes across the five small countries in Europe for 2017 [7]

DALYs Disability-adjusted life years, GBD GlobalBburden of Disease, YLDs years
lived with disability, YLLs years of life lost

GBD
burden
of disease
study
(2017)

Cyprus Iceland Luxembourg Malta Montenegro

DALYs per
100,000

1098 526.98 786.65 1172.67 1254.47

YLDs per
100,000

600.66 429.75 639.76 776.97 847.71

YLLs per
100,000

497.34 97.23 146.89 395.7 406.76

Page 7 of 10Cuschieri et al. Health Res Policy Sys (2021) 19:43

presents a major challenge. The small island of Malta
together with Cyprus have the highest DALYs burden of
the other small countries; they both have one of the high-
est prevalence rates for both diabetes and obesity [10,
14]. Although Malta has had a National Diabetes Plan
in place since 2014, an official diabetes screening frame-
work is not yet present even if various recommendations
have been suggested [10, 31, 40]. For Cyprus, the burden
of disease data show that YLDs are very similar, about
1.5-fold higher, to data on mortality from diabetes, which
possible illustrates that a better diagnosis and regular
blood glucose management of the disease can prevent
premature deaths. For example, in Malta, it is at the dis-
cretion of the family physician or of the individual to seek
out regular blood glucose testing and screening for dia-
betes. A similar picture is seen for Luxembourg.

Health system performance
A slight discrepancy is observed between the diabetes
holistic management approach offered by the health-
care systems of these five small countries. The diabetes
populations residing in Cyprus, Malta and Montenegro
benefit from a free medication scheme as well as system-
atic check-up routines. This holistic approach is justified
considering the high prevalence of diabetes among each
country’s adult population. Regular follow-up enables
early detection of complications and a reduction in the
healthcare burden. Similarly, the diabetes population in
Iceland has the same opportunities, but individuals incur
a minimal fee for the check-up consultations. As Iceland
has the highest GDP per capita of the five small coun-
tries studied here, this health regulation may be justi-
fied, especially as Iceland has not only the lowest overall
disease burden but also the lowest burden from prema-
ture deaths attributed to diabetes, compared to the other
small states studied. Of all the small countries in this
study, Iceland enjoys the lowest overall diabetes’ burden
even though it was noted that it lacks regular evidence-
based data to allow adequate monitoring of population
health. This is in contrast to Luxembourg, which benefits
from access to such data but still has a higher diabetes
burden among its population. Therefore, the plan for a
more organized diabetes management strategy in combi-
nation with better diagnostic and surveillance databases
can complement the monitoring and control within the
provided framework of service delivery to those small
countries who suffer the most from diabetes.

Implications and recommendations
Small states, irrelevant of their GDP (except for Luxem-
bourg) and their health status, appear to have low pri-
orities for regular and ongoing surveys and population
research. The potential reasons for this are multifactorial

and include: the lack of human resources, minimal allo-
cation of grants and funding for research, different gov-
ernance priorities, among others. These issues hinder
the mapping of the burden of diabetes and the associated
evidence-based policy and strategic action plans. Con-
ducting regular health examination surveys with a low
budget and minimal human resources can be achieved
within small countries. Malta’s Health Examination Sur-
vey conducted by the University of Malta suggests that
an epidemiological health examination survey target-
ing diabetes can be successfully conducted with mini-
mal resources [36]. A “toolkit for the development and
implementation of epidemiological surveys in small
populations” has been compiled by the University of
Malta in collaboration with the World Health Organiza-
tion for Health Systems and Policies in Small States [41]
to illustrate how small countries can use their minimal
resources to conduct epidemiological population-based
research. A public interdisciplinary repository may also
be created where researchers can share their research
and data. It is not uncommon that scholars conduct valu-
able studies as part of an academic endeavour, but the
outcomes are not publicly shared with stakeholders. In
small countries, such studies are more likely to be popu-
lation-based and, if easily accessed, the data can be used
effectively for health policy and strategic planning. How-
ever, the mechanisms for the translation of this evidence
into action are unclear. The collection of accurate health-
related data from healthcare facilities can be more feasi-
ble in small countries than in larger ones due to the small
population size. On the other hand, small countries lack
the capacity to conduct local burden of diseases stud-
ies. Therefore, the estimated DALYs obtained from the
GBD study is a useful metric that helps policy-makers to
identify the impact of a disease, such as diabetes, on their
country. Additionally, policy-makers can make use of
such administrative data collection systems when imple-
menting plans to assist with their decisions. It is, there-
fore, important that such resource metrics are brought to
the attention of policy-makers while setting agendas for
health policies and strategic action plans.

Another key challenge that small countries face is the
inability to monitor and evaluate community diabe-
tes public awareness while building up the capacity to
measure the health outcomes following interventions
[33]. Provided that the right tools and data are estab-
lished, small countries are in a better position to imple-
ment interventions and monitor their outcomes due to
their small population size. Awareness of diabetes and
its associated risk factors is not an adequate stand-alone
strategy; rather, it needs to be incorporated into multi-
sectorial interventions that also consider the environ-
ment, social status and cultural setting of the population

Page 8 of 10Cuschieri et al. Health Res Policy Sys (2021) 19:43

[42]. Therefore, it is of immense importance that policy-
makers work with various stakeholders, including local
researchers, to collectively map the country-specific bur-
den of diabetes and set the agenda for population-specific
action plans.

Study limitations
The focus was on diabetes management among small
countries as associated with health policy and strategic
action. This article is based on research literature freely
available in online databases as well as on Ministry of
Health and other releavent websites and data provided
from the appropriate bodies in each of the countries.
Ongoing or unpublished studies have, therefore, not
been included. As such, the value of this work is limited
in these countries (n = 5) and on their characteristics of
setting health policies and implementing management
practices on diabetes. This limitation may prevent the
translation of the relevance or value of the current find-
ings on strategic planning and health policy on health
promotion and disease prevention for diabetes to the
remainder of the excluded countries (n = 6) from the
European countries of the WHO Small Countries Initia-
tive (n = 11). Additionally, further research on address-
ing these differences could, therefore, bring more clarity
on the importance of the context, with emphasis on fac-
tors and performance indicators of small countries in the
European region.

We acknowledge that the article is based on the five
small countries in Europe and that the generalizability of
the findings to other smaller European or other countries
may not be appropriate. Further research is merited to
examine the transfer of knowledge across different small
countries. Although the article is based solely on these
five small European countries, we cannot draw any con-
clusions on differences in the country healthcare system
and structure. A potentially useful model in future stud-
ies might be the Pandemic Risk Exposure Measurement
(PREM) to identify factors that are associated with demo-
graphic characteristics, measures of a country’s activities
and economic and social susceptibilities [43]. For exam-
ple, we can identify such complex variables to map the
impact of diabetes management against the response,
policies and strategies that a country can apply during a
pandemic situation, such as Covid-19.

Study strengths
To our knowledge, this is the first study that has focussed
on mapping the health policy and strategy on diabe-
tes management in five small countries in Europe. The
importance of this work is that it lays the foundation
for a future comparative study between smaller and

medium-sized or larger European states, and for setting
an agenda relevant to them. By collecting and analysing
epidemiological, burden of disease and strategy plans we
have provided a comprehensive analysis of the health pol-
icy landscape related to diabetes. Our results point out
the similarities and differences between these countries
and subsequently set up an evidence-based agenda for a
health-policy framework. Additionally, this study brings
together evidence from multiple national sources, high-
lighting gaps in the process of health policy and strategic
action. These can, in turn, be used by policy-makers in
each of the countries to inform their existing processes
and current practices on diabetes management.

Conclusions
The diabetes epidemic affects every nation including
small countries in Europe. We identified policy docu-
ments, strategies and action plans as well as mapped the
diabetes situation and the resources for Cyprus, Iceland,
Luxembourg, Malta and Montenegro. Despite their small
geographical size, we observed distinct challenges faced
by these small countries as related to their diabetes epi-
demiology, burden of disease and diabetes registers and
national plans. Iceland and Luxembourg have the lowest
prevalence among the five member states, and the low-
est burden from premature deaths, despite being the
only two member states that have no official national
register and no national plan for diabetes. While Malta,
Montenegro and Cyprus provide a free holistic care plan
to patients diagnosed with diabetes, they also have the
highest disease burden from premature mortality. These
findings may also (a) justify the need to perform health
examination surveys for better monitoring and evalua-
tion, (b) acknowledge gaps in the prevention aspects and
set-up of appropriate health population priorities and (c)
identify lack of coherent management approaches within
the health system to support the population they serve.
The key to mapping the burden of diabetes depends on
up-to-date evidence-based data, appropriate infrastruc-
ture and healthcare frameworks supported by the gov-
ernance and multisectoral stakeholders. Such an agenda
can enable the implementation of targeted health policies
and strategic action plans to reduce the burden of diabe-
tes at the population level.

Abbreviations
DALYs: Disability-adjusted life years; GBD: Global Burden of Disease; IDF: Inter-
national Diabetes Federation; IHME: Institute for Health Metrics and Evaluation;
NCDs: Noncommunicable diseases; WHO: World Health Organization; YLDs:
Years lived with disability; YLLs: Years of life lost.

Acknowledgements
The authors would like to thank Dr. Olga Kalakouta, First Health Officer at the
Ministry of Health and Dr. Myrto Azina Chronides, Senior Medical Officer at the

Page 9 of 10Cuschieri et al. Health Res Policy Sys (2021) 19:43

Ministry of Health and President of the National Diabetes Committee for the
provision of data for Cyprus.

Authors’ contributions
SC designed the study protocol. SC and EP have shaped the manuscript. The
other authors provided information and references to their specific countries’
data on diabetes. All authors have approved of the manuscript prior to
submission.

Funding
No funding was required.

Availability of data and materials
All data used are provided within the manuscript.

Ethics approval and consent to participate
Not applicable.

Concept for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests.

Author details
1 Department of Anatomy, Faculty of Medicine and Surgery, University
of Malta, Msida, Malta. 2 MRC Clinical Trials and Methodology Unit, Univer-
sity College London, London, UK. 3 Center for Health System Development,
Institute of Public Health of Montenegro, Podgorica, Montenegro. 4 Service
épidémiologie et statistique, Direction de la Santé, Luxembourg, Luxembourg.
5 School of Health Science, University of Akureyri, Sólborg, Iceland. 6 Akureyri
Hospital, Akureyri, Iceland.

Received: 13 October 2020 Accepted: 23 November 2020

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Mapping the burden of diabetes in five small countries in Europe and setting the agenda for health policy and strategic action

Abstract

Background:
Methods:
Results:
Conclusions:

Key messages
Introduction
Methods

Methodology rationale
Data sources
Data analysis

Results

Epidemiology of diabetes and other related metabolic abnormalities
Diabetes register and national plans
Cyprus
Iceland
Luxembourg
Malta
Montenegro
Burden of diabetes

Discussion

Monitoring and evaluation
Prevention: management plans and execution
Health system performance
Implications and recommendations
Study limitations
Study strengths

Conclusions
Acknowledgements
References

RESEARCH Open Access

Application of machine learning models in
predicting length of stay among healthcare
workers in underserved communities in
South Africa
Sangiwe Moyo1,3* , Tuan Nguyen Doan1,2, Jessica Ann Yun3 and Ndumiso Tshuma3

Abstract

Background: Human resource planning in healthcare can employ machine learning to effectively predict length of
stay of recruited health workers who are stationed in rural areas. While prior studies have identified a number of
demographic factors related to general health practitioners’ decision to stay in public health practice, recruitment
agencies have no validated methods to predict how long these health workers will commit to their placement.
We aim to use machine learning methods to predict health professional’s length of practice in the rural public
healthcare sector based on their demographic information.

Methods: Recruitment and retention data from Africa Health Placements was used to develop machine-learning
models to predict health workers’ length of practice. A cross-validation technique was used to validate the models, and
to evaluate which model performs better, based on their respective aggregated error rates of prediction. Length
of stay was categorized into four groups for classification (less than 1 year, less than 2 years, less than 3 years, and
more than 3 years). R, a statistical computing language, was used to train three machine learning models and
apply 10-fold cross validation techniques in order to attain evaluative statistics.

Results: The three models attain almost identical results, with negligible difference in accuracy. The “best”-
performing model (Multinomial logistic classifier) achieved a 47.34% [SD 1.63] classification accuracy while the
decision tree model achieved an almost comparable 45.82% [SD 1.69]. The three models achieved an average
AUC of approximately 0.66 suggesting sufficient predictive signal at the four categorical variables selected.

Conclusions: Machine-learning models give us a demonstrably effective tool to predict the recruited health
workers’ length of practice. These models can be adapted in future studies to incorporate other information
beside demographic details such as information about placement location and income. Beyond the scope of
predicting length of practice, this modelling technique will also allow strategic planning and optimization of
public healthcare recruitment.

Keywords: Machine learning, Artificial intelligence, Health workers, Modeling, Staff retention

* Correspondence: [email protected]
1Africa Health Placements, Rosebank, Johannesburg, South Africa
3The Best Health Solutions, 107 Louis Botha Avenue, Orange Grove,
Norwood, P.O. Box 92666, Johannesburg, South Africa
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Moyo et al. Human Resources for Health (2018) 16:68
https://doi.org/10.1186/s12960-018-0329-1

http://crossmark.crossref.org/dialog/?doi=10.1186/s12960-018-0329-1&domain=pdf

http://orcid.org/0000-0003-0900-9274

mailto:[email protected]

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

http://creativecommons.org/publicdomain/zero/1.0/

Introduction
The lack of health workforce is a global crisis which
numerous countries have proposed and implemented
intervention plans [1, 2]. However, there is limited data
regarding the impact of these interventions and their
sustainability over a long period of time. Research shows
that the loss of healthcare workers in African countries
(such as South Africa and Ghana) cripples the pre-exist-
ing delicate health system [3, 4]. Hence, the retention of
health workers is essential for the healthcare system per-
formance. These studies also point out that the recruit-
ment of health workers should not only focus on nurses
and physicians, but also on community health workers
(CHWs) to help the primary healthcare systems boost
the coverage and address the basic health needs of soci-
eties [4].
Specifically, healthcare systems in sub-Saharan Africa

(SSA) face a serious human resource crisis, with recent
estimates pointing to a shortfall of more than half a
million nurses and midwives needed to meet the
Millennium Development Goals of improving the
health and wellbeing of the SSA population by 2015 [5].
One of the reasons for this phenomenon is due to
human capital flight (“brain drain”) in the health
profession, especially in the public sector [1, 6]. Migra-
tion of health workers from low- and middle-income
countries (LMICs) to high-income countries is a con-
troversial aspect of globalization, having attracted con-
siderable attention in health policy discourse at both
the technical and political levels [1, 7–9]. The migra-
tion of skilled healthcare workforce translates into a
direct loss of considerable resources to the public
sector of LMICs, as direct benefits only accrue to coun-
tries, which have not invested in educating young
professionals. To make matters worse, in many sub-Sa-
haran countries such as Sierra Leone and South Africa,
there are limited alternatives for the population to seek
healthcare services from the private sector or next
health facility due to inaccessible distance or cost factor
[10].
To maintain a functional health system, most coun-

tries have altered their retirement age in order to
extend the working life of their staffs. Furthermore,
Botswana and South Africa have recruited from other
countries within and outside the continent [7]. Despite
various local and international frameworks, the effect-
iveness of these interventions is yet to be seen [7, 8].
Another challenge lies in the monitoring and evalu-
ation of these frameworks. Recent cross-sectional
reviews of currently available healthcare workforce
database show that in most cases, the systems are
fragmented, unreliable, and cannot be integrated at
both national and international levels, and that in
order for policy-makers to make data-driven decisions,

better database management systems still need to be
developed [1, 2, 8].
A high turnover rate in the health workforce is another

concern as it is costly and detrimental to organizational
performance and quality of care. Healthcare organizations
with high attrition rate not only face issues with the qual-
ity, consistency and stability of services provided to people
in need, but also issues regarding the working conditions
of the remaining staffs such as increased workloads,
disrupted team cohesion and decreased morale [11, 12].
Some studies have focused on the influence of individ-

ual and organizational factors on an employee’s intention
to leave [13]. A World Health Organization (WHO)
study of four African countries shows that the major
reasons behind health worker migration are better sal-
ary, safer environment, living conditions, lack of facil-
ities, lack of promotion, and heavy workloads [8]. Other
studies conclude that better compensation package with
good work-life balance is the primary reason to migrate
[6, 14, 15]. On the other hand, one of the obstacles to
migration is language barrier, which lies at the basis of
patient care [16, 17]. Patients express their distress by
describing their symptoms and pain and report changes
in health status to professionals. Nurses or doctors need
the current and technical language fluency to communi-
cate under stress and duress with one another, members
of the teams, and patient families [6].
Another healthcare policy concern is the misdistribution

of healthcare workforce between urban and rural areas. It
prevents equitable access to health services, contributes to
increased health-care costs and underutilization of health
professional skills in urban areas, and remains a barrier to
universal health coverage [6].
Overall, the human capital flight of local health pro-

fessionals, the high turnover rate, and the shortage of
workers in the public sector of South Africa thus
demands further investment in attracting and retain-
ing foreign healthcare staffs that stay for an extended
period of time. The WHO has also issued global rec-
ommendations to improve the rural recruitment and
retention of the health workforce [18]. This is pivotal
to the delivery of healthcare in rural and remote areas
of South Africa. A study has shown that 84% of South
African population uses public healthcare, served by
only 30% of the trained and certified doctors [19].
Generally, sub-Saharan Africa faces severe lack of
healthcare workers, with only 3% of the world’s total
medical staff while facing 24% of the global burden of
disease [8]. The arrival of foreign medical workforce
and their placement in the public health sector
reduces the two-front misdistribution of physicians,
alleviates the lack of human resources in public rural
facilities, and improves access to healthcare to people
in rural areas [8].

Moyo et al. Human Resources for Health (2018) 16:68 Page 2 of 9

To date, greater efforts have focused on recruitment,
with significantly less attention to workforce retention.
As aforementioned, a challenge to improve health access
in rural areas is to maintain high retention rate of the
medical workforce. Currently, there are few empirical
studies regarding the factors that influence the length of
practice [14, 17]. Previous attempts to identify these fac-
tors mainly focus on worker satisfaction at medical facil-
ities and retention strategy of staffing agencies [17].
There are some recent research into the correlation be-
tween employee demographic information and the suc-
cess of retention effort in public health facilities [14].
This paper aims to develop a predicting tool for the

length of practice of foreign healthcare workers, given
their demographic information. Machine learning
methods are well-suited for this challenge. Rather than
traditionally considering the effect of demographic vari-
ables on the length of practice one after another, machine
learning method examines all potential predictors simul-
taneously in an unbiased manner, and identifies pattern of
information that are useful to make prediction.

Methods
Study design
A quantitative retrospective cohort study was conducted
using secondary data, collected from the Africa Health
Placements (AHP).

Study setting
South Africa Health, healthcare worker population in
underserved communities and distribution and retention
levels. AHP recruits foreign and locally qualified health
professionals to be placed in underserved communities
in South Africa. Underserved areas like rural areas often
face challenges in recruiting and retaining health
workers, government has responded with programmes
like compulsory community service and rural allowance
to address this challenge.

Data acquisition
Longitudinal individual health worker records are main-
tained at AHP. These health workers included profes-
sionals from South Africa and the rest of the world
seeking employment in underserved facilities in South
Africa. Data was collected using two methods (i) cus-
tomized online portal completed by healthcare workers
(HCW) and (ii) interviews by recruitment officers
through email, Skype, and telephonic conversations.
Data were captured onto a database and customer man-
agement system called Docwize. The online portal is
available at the AHP website as a contact form. Once
registered, the HCW receives login details to complete
their application on Docwize. This system allows them
to input personal and professional information, upload

certificates, which would then be verified with the re-
spective regulatory authorities, and be informed about
the next steps until they secured a job offer. The HCW
have an option of completing the application online or
supplying the details to the recruitment officers who
then update the system. It takes an average of 18 months
to complete the recruitment process, 75% of the HCW
were discouraged by the regulatory delays resulting in
incomplete data. The length of stay was continuously
monitored during their employment contract. Emails
and telephonic contact are used to establish their last
date of employment at a particular facility.

Statistical analysis
Dataset description and manipulation
We took a complete cases approach, using only data
from successfully recruited health workers without
missing observations. The Africa Health Placements
dataset contains 62 variables and 13 698 entries, in
which there were 2079 successfully recruited practi-
tioners. Among these 2079 professionals, some chose
not to provide personal information such as marital sta-
tus or gender. After data cleaning, there were 1838
entries with completed fields to meet the requirements
of this study.
The variables that are used to develop our machine

learning models are chosen based on their availability in
the AHP data system. They are nationality, profession,
relationship, and gender. Since there are a lot of missing
values in our age variable dataset, a complete case ap-
proach with age could have further reduced the dataset
to merely 914 entries and undermine the ability of the
model to learn from existing data. Hence, we excluded it
from the final analysis. Notably, all of our four predictors
are categorical variables. A challenge with having cat-
egorical variables in machine learning is that to fully rep-
resent each variable, we have to use a large number of
dummy variables to represent each level within the vari-
able. For example, since our data had records from 145
countries, we needed 144 dummy variables to represent
all existing countries. This method would result in a very
sparse dataset and usually not useful in predictive mod-
elling. Hence, we transcribed each variable as follows:

Nationality: categorical data of 145 different countries.
Instead of recording nationality as it is, the nationality
variable is transcribed based on World Bank’s classification
of countries into 4 categories: low income, lower middle
income, upper middle income, and high income.
Professions: categorical data of 22 different registered
professions, recorded into 3 different categories: doctor,
nurse, and other
Gender: categorical data of 2 levels: male and female

Moyo et al. Human Resources for Health (2018) 16:68 Page 3 of 9

Relationship status: categorical data of 3 levels: married,
single, or other.

Machine learning model development
With a large recruitment and retention dataset from
AHP, we built three machine learning predictive models
using relevant demographic data. We evaluated the
models’ performance by doing 10-fold cross-validation.
The aim was to choose a model that performs signifi-
cantly better in predicting length of practice.
As shown on Table 1, three different machine learning

classification models (multinomial logistic regression,
decision tree, and Naive Bayes Classification) were used
to train the dataset. The issue was approached as a
classification, rather than a regression problem, as we
aimed to classify a successful recruit into one of the four
mutually exclusive groups (less than 1 year, less than 2
years, less than 3 years, and more than 3 years). The use
of a regression method is not optimal in this case, due
to (i) the lack of quantitative numerical variables in our
demographic information, (ii) the wide range of value of
the dependent variables (length of practice measured in
days), and (iii) the non-continuous nature of the
dependent variables. A regression method would require
a much larger dataset to arrive at a model of relatively
acceptable fit. With our current available dataset, the
experimental fit is approximately 18% with high internal
sum of squares. Moreover, in strategic workforce plan-
ning, a precise prediction of the length of practice in
days (or months) is generally not expected. A prediction
of whether a specific healthcare worker will stay for 1
year, 2 years, or longer is usually acceptable for most
intents and purposes.

Cross-validation
To decide which of the three models perform best, we
have to see their ability to generalize and predict new,
unseen data. A challenge to our research was the lack of
test data which we could have used for model evalu-
ation. Conventionally splitting our existing data into a
80/20 ratio—80% of the data for training and 20% for

testing—was an option, but not optimal as we wanted to
use all data available for training.
We examined our three models with a technique

called 10-fold cross-validation. Ten-fold cross-validation
works as follows: we randomly partition the original
dataset into 10 disjoint subsets, use nine of those subsets
in the training process, make predictions about the
remaining subset, and record the misclassification error.
To avoid opportune data splits, we average misclassifica-
tion error across the 10 folds. A comparison between
the average misclassification errors of the three machine
learning models allowed us to decide which model per-
forms best on unseen data.

Results
Three machine learning models were trained, and a
10-fold cross validation technique was used to attain
evaluative statistics. The three models attain almost identi-
cal results, with negligible difference in accuracy. The
“best”-performing model (multinomial logistic classifier)
achieves a 47.34% [SD 1.63] while the decision tree model
achieves an almost comparable 45.82% [SD 1.69]
(Table 1).
Multiclass area under the curve (AUC) was computed

by building multiple receiver operating characteristic
(ROC) curves (one class versus another) and taking the
average, as defined by Hand and Till [20]. The three
models achieve an average AUC of 0.66 (multinomial lo-
gistic at 0.6652, decision tree 0.6635, Naive Bayes
0.6602), suggesting sufficient predictive signal at the four
selected categorical variables.
Overall, the three models had significant accuracy

in classifying the length of stay of healthcare workers
(p value < 2.2e−16) (Table 1). Additionally, Kappa
statistics was also computed, in order to measure
how much better each of the classifiers is performing
over the performance of a classifier that simply
guesses at random according to the frequency of each
class [21]. The Cohen’s Kappa statistics of the multi-
nomial logistics, decision tree, and Naive Bayes are
0.2658, 0.2649, and 0.2521 respectively, suggesting a

Table 1 Machine learning results

Techniques

Multinomial logistic Decision tree Naive Bayes

Accuracy 47.34% [1.63] 45.82% [1.69] 47.01% [1.62]

95% CI (46.22, 50.84) (46.66, 51.28) (45.19, 49.81)

AUC 0.6652 0.6635 0.6602

No information rate [NIR] 0.376 0.376 0.376

P value [Acc > NIR] < 2.2e−16 < 2.2e−16 < 2.2e−16

Cohen’s Kappa 0.2658 0.2649 0.2521

Moyo et al. Human Resources for Health (2018) 16:68 Page 4 of 9

fair (but not substantial) agreement between predic-
tion and response adjusted by the amount of agree-
ment expected by chance.
All three models perform reasonably well at identifying

those who are likely to stay for less than 1 year (Table 2).
The sensitivity of this class was greater than 75% for all
three models, showing that they correctly identify more
than ¾ of those who are likely to stay less than 1 year.
Specificity of this class is not particularly high (all lower
than 65%), so all three models do not do as well in iden-
tifying those who are staying for more than 1 year. How-
ever, with a negative positive rate as high as 84% across
the three techniques, it means that when the model
negatively classifies a person out of those who stay for
less than 1 year, such classification is likely to be correct.
In contrast, all three models perform poorly at identi-

fying those who are staying between 2 and 3 years
(Table 2). With sensitivity at as low as 0% (decision tree)
and specificity up to 100%, the three models must have
learned to negatively assign a majority (all in decision
tree case) out of this class. This is likely the result of
imbalanced data sample with too little sample data of
this class (Fig. 1).

Comprehensive data analysis
In general, more males (997, 54%) than females (861,
46%) were recruited (Table 3). Males stay on average
187.78 days more than females do. South Africa has
supplied the greatest number of health workers (381,
41%), followed by the United Kingdom (361, 39%),

Nigeria (106, 11%), and Netherlands (86, 9%) (Table 3).
Doctors (1538, 83%) were the most recruited health
workers and then nurses (107, 6%) and other profes-
sionals (193, 10%). With regard to relationship status,
single healthcare workers constituted 61% of the
recruited, 31% were married, and 8% were cohabiting
(Table 3, Figs. 1, 2, and 3).
Figure 4 shows two world heat maps that represent (a)

the number of successful recruits from each country and
(b) the average length of practice among those in these
countries. The two maps point to an observation: AHP
as a health placement organization is not very successful
in recruiting from some countries, e.g. Russia, but once
we do, the recruits tend to stay for an extended period
of time. However, the sample size casts some doubts on
this observation. Some countries have very high average
length of stay, simply because we have a very small sam-
ple size of them.

Discussion
This research shows that a majority of foreign qualified
healthcare workers (1497 out of 1838, 81%) stay at their
placement facilities for less than 3 years. While a con-
stant rate of foreign recruitment per year can “fill the
gap” in paper, the low average length of practice signifies
a hidden cost of recruiting, relocating, and training of
new healthcare professionals. Effective workforce plan-
ning from government or non-profit organizations, thus,
requires a tool to predict the length of practice of in-
coming health professionals.

Table 2 Predictions of length of stay across the three models

Less than 1 year Less than 2 years Less than 3 years More than 3 years

Multinomial logistic techniques

Sensitivity 0.7685 0.3248 0.0369 0.5425

Specificity 0.6548 0.8503 0.9766 0.7896

Positive predictive value 0.5728 0.4533 0.2340 0.3700

Negative predictive value 0.8244 0.7673 0.8398 0.8834

Balanced accuracy 0.7166 0.5876 0.5068 0.6661

Decision tree techniques

Sensitivity 0.7858 0.3740 0.000 0.4897

Specificity 0.6469 0.8075 1.000 0.8150

Positive predictive value 0.5728 0.4260 NaN 0.3761

Negative predictive value 0.8337 0.7716 0.8379 0.8751

Balanced accuracy 0.7164 0.5908 0.5000 0.6524

Naive Bayes techniques

Sensitivity 0.7728 0.2658 0.0403 0.5630

Specificity 0.6391 0.8752 0.9760 0.7675

Positive predictive value 0.5633 0.4485 0.2449 0.3556

Negative predictive value 0.8236 0.7573 0.8401 0.8852

Balanced accuracy 0.7059 0.5704 0.5081 0.6653

Moyo et al. Human Resources for Health (2018) 16:68 Page 5 of 9

Fig. 1 Number of subjects categorized by (from left to right, up to down) length of practice, professions, relationships, and countries

Table 3 Length of stay by gender, nationality, profession, and relationship status

Mean length of stay (days) Standard deviation (sd) Sample (n) Percentage (%)

Gender

Female 603.48 499.0 861 46

Male 791.26 630.9 997 54

Total 1 838 100

Nationality (top 4)

South Africa 548.65 388.1 381 41

United Kingdom 475.11 373.3 361 39

Nigeria 1 096.09 719.7 106 11

Netherlands 753.36 532.7 86 9

Registered profession

Doctor 714.58 588.4 1 538 83

Nurse 575.38 498.2 107 6

Other supporting staff 684.31 550.9 193 10

Total 1 838 100

Relationship status

Single 625.22 530.64 1 114 61

Married 868.46 659.26 574 31

Other 651.12 651.12 150 8

Total 1 838 100

Moyo et al. Human Resources for Health (2018) 16:68 Page 6 of 9

The three models attain significantly above chance
results, with the average AUC of approximately 0.66 (multi-
nomial logistic at 0.6652, decision tree at 0.6635, Naive
Bayes at 0.6602), suggesting sufficient predictive signal at
the four categorical variables selected. This is an indication
that applying and retraining machine learning models with
available datasets, Human Resource for Health decision

makers can effectively source healthcare workers who are
most likely to stay the longest in underserved communities.
Machine learning must be applied together with other

qualitative methods like exit interviews so as to give an
in-depth understanding of the healthcare worker per-
ceptions and experiences that relate to their length of
stay. A mixed method would have generated a better

Fig. 2 Length of stay as function of relationship, colour by gender and grid by income group

Fig. 3 Decision tree on income, gender and profession

Moyo et al. Human Resources for Health (2018) 16:68 Page 7 of 9

understanding of why certain gender, countries, age,
and experience tend to stay longer than others.

Limitations of the study
Incomplete fields in the data were another issue as many
candidates were excluded from the study due to missing
information. We could not obtain age as one of the pre-
dictors, although we recognized that it could potentially
influence health worker long-term plan to stay. Our
issue with incomplete data relates directly to the inef-
fective database system issue that is common among the
public sector in South Africa [1, 2, 8]. Although in the
short run, installing and enabling a more effective

database system imposes a cost challenge to healthcare
non-profits and public sector, such system is likely to
make tremendous impacts as the machine learning
models can be further improved by learning from a lar-
ger, high-quality dataset. In the meantime, there is a po-
tential for the public sectors and NGOs to collaborate
and involve in data sharing that could empower the
training process of machine learning algorithms.

Conclusions
Machine learning models give us an effective tool to pre-
dict the recruited health workers’ length of practice. These
models can be adapted beyond the scope of demographic

Fig. 4 Map showing world distribution of a number of candidates sourced from each country and b average length of practice by these
candidates from each respective country

Moyo et al. Human Resources for Health (2018) 16:68 Page 8 of 9

information (i.e. information about placement location, in-
come), allowing strategic planning and optimization of
public healthcare recruitment.

Abbreviations
AUC: Area under the curve; HCW: Healthcare workers; LMIC: Low- and middle-
income countries; NGO: Non-governmental organization; ROC: Receiver operating
characteristic; SSA: Sub-Saharan Africa; WHO: World Health Organization

Acknowledgements
The authors would like to thank the African Health Placement for providing
the dataset used in the study.

Funding
This research received no specific grant from any funding agency in the
public, commercial, or not-for-profit sectors.

Availability of data and materials
The dataset supporting the conclusions of this manuscript is available with
the corresponding author and will be made available in an anonymized
version on reasonable request.

Authors’ contributions
All authors contributed toward conceptualization, data analysis, drafting, and
critically revising the paper and agree to be accountable for all aspects of
the work. All authors also read and approved the final manuscript.

Ethics approval and consent to participate
Permission to conduct the study was obtained from Africa Health Placements.
The researchers followed the highest standards to protect confidentiality and
anonymity of subject data. All identifying information of individual subjects
such as name, address and date of birth were removed from the dataset prior
to the study.

Competing interests
The authors declare that they have no competing interests.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.

Author details
1Africa Health Placements, Rosebank, Johannesburg, South Africa. 2Yale
University, New Haven, CT, United States of America. 3The Best Health
Solutions, 107 Louis Botha Avenue, Orange Grove, Norwood, P.O. Box 92666,
Johannesburg, South Africa.

Received: 15 December 2017 Accepted: 30 October 2018

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