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“With Women”  Midwives for Afghanistan

Reproductive HealthWorkforce Developmentin Afghanistan

2002 - 2009

Jeffrey Smith, MD, MPH

Asia Regional Technical Director

Jhpiego

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Presentation Outline

Review the reproductive health situation in Afghanistan Discuss the human resource constraints

Describe some key considerations in workforcedevelopment/task shifting in reproductive health

Present the results of interventions in Afghanistan

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RH Situation 2002

High maternal and newbornmortality (MMR 1600 / 100 000 LB)

Few RH providers 40% facilities with female staff 467 midwives in country

Non-uniformity of qualification Out of date skills

No functional schools for trainingmidwives – schools closed by Taliban

RH de-emphasized in medical curriculum Disarray of system for supporting human

resources for health STRATEGY: support the education and

deployment of large numbers ofmidwives rather than doctors

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Task Shifting

Putting clinical capabilityin hands of appropriateperipheral workers sothat key components ofhealth care can bediffused to greatestnumber of people.

Should not be atemporary fix!

But a professional focus!

4

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What works, who works, and where?

Health Center IntrapartumCare Strategy Training of Midwives

Staffing of Health Centers

Health system linkages

Capability in Basic EmOC Clarity about “skilled attendant”

Policy support for clinical authority

Educational system to achievecompetency and capability

Lancet 2006Maternal Survival Series

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Workforce Assessment & Planning

Array of semi

trained, partially

skilled workers

NEEDHAVE

Core group of

leaders and

academicsGroup of managers

and teachers

Bulk of personnel

should be service

providers

Cries of crisis:

“Something is

better than

nothing”

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Normatizing the Health Workforce

Re-establish health systemaccountability

Census of health workers Including where they work

Testing: knowledge + skills

Phased (re)deployment Registration and licensure Upgrade programs Education programs

Set selected practical policies Immediate need and long term

view Emergency Development

Staff 

functioning

as midwives

QualifiedAlmost

qualifiedUnqualified

License and

Deploy

Upgrade

Standardize

and Retain

Retrain to

qualification,

Redeploy

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Importance of Standardization

Single, standard approach toupgrading RH workforce maybe more efficient, especiallyin post-conflict settings

Fragile health systems don’thave resources to compareand contrast different, non-uniform approaches atmacro level

Uniformity of professional andcommunity expectation,supervision, supply, etc.

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Policy and Structure

Basic Package of Health Services

Maternal Health / RH Service delivery guidelines Guide for re-establishing services and in-service training/pre-

service education

National MW education policy Midwifery job description

Single, unified national midwifery curriculum

Assessment materials and criteria

of students graduation and licensure of clinical facilities quality of care and clinical certification of schools school accreditation

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Standardization in Action

Standard curriculum anddetailed teaching resources

National accreditation system Based on “recipe” for

establishing and running amidwifery school

Structured technicalassistance framework

Increased local capacity and

improved ability to supporttraining programs and schoolsin remote or insecure areas

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Keep it clinical

Ensure that the focusremains on clinical skilldevelopment

MW program in Afghanistan

was SHORTENED from 3years to 2 and unnecessarytopics were removed Semester 1: Normal

Pregnancy

Semester 2: Complications Semester 3: Family Planning,

RH and Child Care

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Keep it local

Retention, deployment,

selection and education

all related:

local control increases local

commitment

Train midwives where

they are needed

Focus on local, “micro-

deployment”

Caveat: ensure adequate

educational and clinical

capacity

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Results 2002 – 2009

5 midwifery schools re-opened and 26 newmidwifery schools established

Midwifery deployment 1961 new midwives 85% deployed 86% working as midwives 

Health centers with 1+

female health worker:25% 83%

Health centers staffed with 1+ midwife: <10% 61%

Standardized system to improve quality in midwifery

services and education

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Working as Midwives, 2009

P r  o gr  am

 C  ur r  en t  l   y s t   u d  yi  n g

E nr  ol  l   e d 

 Gr  a d  u a t   e d 

Dr  o p- o u t   s

 %  Gr  a d  u a t   e d 

D e pl   o y e d  /  

E m pl   o y e d 

 % D e pl   o y e d  /  E m p

l   o ym en t   of   gr  a d  u a t  

 e d 

 C  ur r  en t  l   yw or k i  n g

 (   a s of  M a y ,2  0  0  9  )  

 %  c ur r  en t  l   yw or k i  

n g of   gr  a d  u a t   e d 

 C  ur r  en t  l   yw or k i  n g

 of   d  e pl   o y e d  /   em pl  

 o y e d 

IHS 167 1232 1103 129 90% 890 81% 754 68% 85%

CME 509 886 858 28 97% 785 91% 694 81% 88%

Total 676 2118 1961 157 93% 1675 85% 1448 74% 86%Local CME schools have greater 

success than regional IHS programs.

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Deliveries by Skilled AttendantsSelected Provinces/Districts 

Tarkhar:

from 12%

to 21%

Herat:

from 13%

to 27%

Examples of 

increase in

skilled birth

attendant

coverage at

birth:

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Professionalization of MidwiferyAfghan Midwives Association

Founded in 2005

Provincial branch in mostprovinces

Roles: Advocacy

Professional development

Networking and support

Has raised personal andprofessional stature ofmidwifery “This is the first time I have

ever belonged to anything 

other than my own family. I 

feel proud to be a midwife.” 

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Reflection on “Gender”

Task shifting should not become

Clinical Shortcutting

Shortcuts in medical education vs.Shortcuts in midwifery education

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Conclusions

Vibrant maternal health / reproductive healthworkforce must be composed substantially ofmidwives

Midwives must be empowered professionallyand deployed rationally

Consistency in the service delivery andeducational system is essential for midwives tohave skills and retain skills

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Acknowledgements

Ministry of Public Health,Afghanistan

Donors – USAID, WorldBank and EuropeanCommission

Non GovernmentalOrganization partners,WHO, UNICEF, andmany other supporters ofmidwifery

Staff and students of allmidwifery schools

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Thank you

Questions?

Comments?

Observations?