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Human Resources for Maternal

Health and Task-Shifting

January 6th, 2010

Woodrow Wilson Center

Washington, DC

Seble Frehywot MD, MHSA

Assistant Research Professor of Health Policy and Global HealthThe George Washington University

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Outline

Current Human Resources for Health (HRH) status formaternal health

Types of task shifting

Regulation of task shifting and expanded service roles

Key lessons learnt from the "WHO Task-shifting

Recommendation and Guidelines

Key future challenges and strategies

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World Workforce & Health Status:

The Global Picture

SOURCE: JLI 2004./ WHO 2006 World Health Report

< 23 HCP/10,000 unlikely to achieve MDG

2 physicians/10,000

11 nurses and

mid wives/10,000

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Maternal Mortality Ratio (per 100,000 live

births) and Regional Averages

Source: WHO (2005). The World Health Report 2005 Make Every Mother and Child Count. Geneva, World Health Organization

Source: for Regional Averages : WHO: World Health Statistics 2009

AFRO

900

SEARO

450

AMR

O

99

EMR

O

420

WPR

O

82

EURO

27

The average global Maternal Mortality Ratio of 400 maternal death

per 100,00 live births in 2005 has barely changed since 1990.

Source: for Regional Averages : WHO: World Health Statistics 2009

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Global Causes of Maternal Mortality and

the Need for Skilled Workforce

Hemorrha25%

Infectio

15%

Ec lamp s i

12%

Obs tructed La

7%

Unsafe Abo rti

13%

Other Direct Ca u

8%

Indirect Cau s

20%

Source: World health Report, 2005

**Good quality maternal health services

are not universally available

and accessible

** > 35% receive no

Antenatal Care

** ~ 50% of deliveries unattended

by skilled provider

** ~ 70% receive no postpartum care

during 1st 6 weeks following delivery

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Health Workers Save Lives

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Too Many Preventable Deaths!!...

Source: WHO (2005). The World Health Report 2005 Make Every Mother and Child Count. Geneva, World Health Organization

Source: for annual numbers : WHO: World Health Statistics 2009

Annually,

536,000women

die of pregnancy related

complications

99% in developing countries

(1 per minute)

~ 1% in developed

countries

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Task Shifting Types

Task shifting I

Task shifting II

Task shifting III

Task shifting IV

Specialized Physicians

Doctors

Non-physician clinicians(clinical officers, health officers)

Registered Nurses

& nurse mid-wives

Nursing

Assistants&

CommunityHealth Care

Worker

Enrolled nurses

Expert Patients

REGULATIONSupervision, Delegation,

Substitution,Enhancement, Innovation

Task shifting 0

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Expanded Service Roles (ESR)(Example TS I)

Medical Doctor Non-physician Clinicians(e.g. AMO, Clinical Officers, Health Officers)

Diagnostic, Prescriptive

Case Treatment andManagement Authority

Delegation or

Supervision

Pre-service trainingcoupled

with additional in-

service

training

Expanded Service Roles

(ESR)SOP include:

Medical care and management, OBGYN (C/S),minor Surgery, Anesthesia,

Orthopedics, Ophthalmology,

Dermatology etc.

Regulatory

Fram

ework

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Expanded Services Role (ESR)

TS0 and TS I

ESR from specialists to GPs

- C/S, management of complicated cases

ESR and NPCs

- C/S, management of complicated cases

Matching tasks needed with competency

Review of curricula to reflect the need on the ground

Buy-in from professional associations

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Expanded Services Role (ESR)

TS IIITBA, CHWs

Traditional Birth Attendants---Community based, community women comfortable with them

Limited technical skills

Need adequate training, supervision and supplies

Tasks--ESR

Antenatal care

- Risk screening..train to identify risk cases earlier on and refer to higher care site

- Motivate/empower not to keep women away from life-saving interventions due to

false reassurance

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Scope of Practice &

Competencies

Standards of Care

Standard Pre-Service

Education & TrainingLicensing &Registration &

Certification

Standard

In-Service Training &

Certificate

Recruitment, Deployment,

Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision/Mentoring& Accountability

Health CareWorkers

Financing &

Sub-national

Implementation

1

2

3

4

5

6

7

8 9

Professional

Councils

MOH

ProfessionalPractice Acts

Professional Councils,

Professional Associations,

MOH

Normative Bodies (WHO)

MOE, MOH

Training Institutions,

Professional Councils,

Professional AssociationsProfessional Councils, MOH

MOH. MOE,

Training Institutions,

Professional Councils

Professional Associations

Public Service

Agency,MOH,MOF, IMF,

Local Government,

Professional Association

MOL, ILO,MOH,

Professional Association,

Local Government

MOF, Local Government,

MOH, IMF, WB

Professional Council, MOH,

Other Health Care Providers

Maternal Health

Treatment and Care

Policies & Guidelines

Labor Policies

Regulating HCWs and Who is Involved?

Decentralization Policy

Civil Service Policies

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Types of Regulation

Laws and statutes

Regulations

Guidelines

General and specific maternal health care provider policies

Program guidance

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Why Develop A Regulatory Framework?

To build national and international support and commitment

To ensure quality and safety in the delivery treatment, care and preventionwhile task-shifting occurs

To promote the sustainability of task-shifting/task-reallocation practices Legal conditions and rights of practice Hiring and promotion policies and procedures Standardize remuneration and salaries

To guide the development of standardized education and training programs

to support task-shifting/task-reallocation

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Lessons from the "WHO Task-shifting

Recommendation and Guidelines?

Adaptability of the TS R&G to other issues

Outlining/identifying task

Matching task with competency

Creating optimal skill mix

Developing regulatory framework to ensure quality and

safety of care and services

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Challenges and Strategies

Not enough HCWs

No optimal skill-mix at different care-site levels

Competency not matching need on the ground

Buy-in for revision of curricula

Creating critical mass and retaining faculty/supervisors at different levels---quality/supervision

Decentralizing targeted tertiary care to District Hospitals

Retaining needed HCWs in needed geographical areasretention and motivationpolicies

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Policies need to address interventions at needed levels

Regional Referral Hospitals

also calledTertiary Care Centers

Health Centers (Type A and B)also called

Primary (First)-Level Health Care Facilities

or

Health Clinics

District Hospitalsalso called

Second-Level Health Care Facilities

orFirst-Referral Level Facilities

SOURCE: WHO (2005): WHO Recommendations for Clinical Mentoring to Support Scale-up Of HIV Care, Antiretroviral Therapy

and Prevention in Resource-Constrained Settings.

Health PostsAlso called

Health Houses

CONCE

NTR

ATE

ON

THESE

3

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Pregnancy is NOT a Disease

Global initiatives to scale up health workforce

The Question is

Whom to train?

Where will they be trained?

How will they be trained?

What will they be trained for?

To work where will they be trained?

How will quality & safety of service be ensured?

How will they be retained in needed areas?

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Pregnancy is NOT a Disease

There is a tide in the affairs of (wo)men

which, taken at the flood, leads on to fortune;

Omitted, all the voyage of their lifeIs bound in shallows and in miseries.

On such a full sea are we now afloat;

And we must take the current when it serves,

or lose the ventures before us. William Shakespeare, Julius Caesar