Human Resources for Maternal Health and Task-Shifting January

Human Resources for Maternal Health and Task-Shifting January 6 th, 2010 Woodrow Wilson Center Washington, DC Seble Frehywot MD, MHSA Assistant Research Professor of Health Policy and Global Health The George Washington University 1

Outline n Current Human Resources for Health (HRH) status for maternal health n Types of task shifting n Regulation of task shifting and expanded service roles n Key lessons learnt from the "WHO Task-shifting Recommendation and Guidelines” n Key future challenges and strategies 2

World Workforce & Health Status: The Global Picture < 23 HCP/10, 000 unlikely to achieve MDG 2 physicians/10, 000 11 nurses and mid wives/10, 000 3 SOURCE: JLI 2004. / WHO 2006 World Health Report

Maternal Mortality Ratio (per 100, 000 live births) and Regional Averages EURO 27 AMR O 99 EMRO 420 SEARO 450 AFRO 900 The average global Maternal Mortality Ratio of 400 maternal death per 100, 00 live births in 2005 has barely changed since 1990. WPR O 82 Source: for Regional Averages : WHO: World Health Statistics 2009 4 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

Global Causes of Maternal Mortality and the Need for Skilled Workforce **Good quality maternal health services are not universally available and accessible ** ~ 50% of deliveries unattended by skilled provider Source: World health Report, 2005 ** > 35% receive no Antenatal Care ** ~ 70% receive no postpartum care 5 during 1 st 6 weeks following delivery

Health Workers Save Lives 6

Too Many Preventable Deaths!!. . . Annually, 536, 000 women die of pregnancy related complications 99% in developing countries (1 per minute) ~ 1% in developed countries 7 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

Task Shifting Types Task shifting II Task shifting I Non-physician clinicians (clinical officers, health officers) Doctors REGULATION Registered Nurses & nurse mid-wives Supervision, Delegation, Substitution, Enhancement, Innovation Task shifting 0 Specialized Physicians Expert Patients Task shifting III Enrolled nurses Nursing Assistants & Community Health Care Worker Task shifting IV 8

Expanded Service Roles (ESR) Regulatory Framework (Example TS I) Delegation or Supervision Medical Doctor Non-physician Clinicians (e. g. AMO, Clinical Officers, Health Officers) Pre-service training coupled with additional inservice training Expanded Service Roles (ESR) SOP include: Medical care and management, OBGYN (C/S), minor Surgery, Anesthesia, Orthopedics, Ophthalmology, Dermatology etc. Diagnostic, Prescriptive Case Treatment and Management Authority 9

Expanded Services Role (ESR) TS 0 and TS I n ESR from specialists to GPs - C/S, management of complicated cases n ESR and NPCs - C/S, management of complicated cases n Matching tasks needed with competency n Review of curricula to reflect the need on the ground n Buy-in from professional associations 10

Expanded Services Role (ESR) TS III—TBA, CHWs Traditional Birth Attendants---Community based, community women comfortable with them n Limited technical skills n Need adequate training, supervision and supplies Tasks--ESR n 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 11

Regulating HCWs and Who is Involved? Professional Council, MOH, Other Health Care Providers MOF, Local Government, MOH, IMF, WB Decentralization Policy 8 MOL, ILO, MOH, Professional Association, Local Government Labor Policies Public Service Agency, MOH, MOF, IMF, Local Government, Professional Association Professional Practice Acts 9 Supervision/Mentoring & Accountability Financing & Sub-national Implementation Professional Councils Scope of Practice & Competencies 1 Working Conditions 7 Recruitment, Deployment, Promotion, Salary, & 6 Other HR Issues Maternal Health Treatment and Care Policies & Guidelines Health Care Workers 2 Standards of Care Civil Service Policies 5 MOH. MOE, Training Institutions, Professional Councils Professional Associations Standard In-Service Training & Certificate 3 4 Licensing & Registration & Certification Professional Councils, MOH Professional Councils, Professional Associations, MOH Normative Bodies (WHO) Standard Pre-Service Education & Training MOE, MOH Training Institutions, Professional Councils, Professional Associations 12

Types of Regulation n Laws and statutes n Regulations n Guidelines n General and specific maternal health care provider policies n Program guidance 13

Why Develop A Regulatory Framework? n To build national and international support and commitment n To ensure quality and safety in the delivery treatment, care and prevention while task-shifting occurs n To promote the sustainability of task-shifting/task-reallocation practices n Legal conditions and rights of practice n n Hiring and promotion policies and procedures Standardize remuneration and salaries n To guide the development of standardized education and training programs to support task-shifting/task-reallocation 14

Lessons from the "WHO Task-shifting Recommendation and Guidelines”? n Adaptability of the TS R&G to other issues n Outlining/identifying task n Matching task with competency n Creating optimal skill mix n Developing regulatory framework to ensure quality and safety of care and services 15

Challenges and Strategies n Not enough HCWs n No optimal skill-mix at different care-site levels n Competency not matching need on the ground n Buy-in for revision of curricula n Creating critical mass and retaining faculty/supervisors at different levels---quality/supervision n Decentralizing targeted tertiary care to District Hospitals n Retaining needed HCWs in needed geographical areas—retention and motivation policies 16

Policies need to address interventions at needed levels Regional Referral Hospitals also called Tertiary Care Centers District Hospitals O N TH ES E 3 also called Second-Level Health Care Facilities or First-Referral Level Facilities AT E Health Centers (Type A and B) CO NC E NT R also called Primary (First)-Level Health Care Facilities or Health Clinics Health Posts Also called Health Houses 17 SOURCE: WHO (2005): WHO Recommendations for Clinical Mentoring to Support Scale-up Of HIV Care, Antiretroviral Therapy and Prevention in Resource-Constrained Settings.

Pregnancy is NOT a Disease Global initiatives to scale up health workforce The Question is n Whom to train? n Where will they be trained? n How will they be trained? n What will they be trained for? n To work where will they be trained? n How will quality & safety of service be ensured? n How will they be retained in needed areas? 18

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 life Is 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 19