1 Human Resources for Maternal Health and Task-Shifting January 6 th, 2010 Woodrow Wilson Center Washington, DC Seble Frehywot MD, MHSA Assistant Research.

1

Human Resources for Maternal Health and Task-Shifting

January 6th, 2010

Woodrow Wilson CenterWashington, DC

Seble Frehywot MD, MHSAAssistant Research Professor of Health Policy and Global Health

The George Washington University

2

Outline

Current Human Resources for Health (HRH) status for maternal 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

3

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

4

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

AFRO900

SEARO450

AMRO99

EMRO

420

WPRO82

EURO27

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

5

Global Causes of Maternal Mortality and the Need for Skilled Workforce

Hemorrhage25%

Infection15%

Eclampsia12%

Obstructed Labor7%

Unsafe Abortion13%

Other Direct Causes8%

Indirect Causes20%

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

6

Health Workers Save Lives

7

Too Many Preventable Deaths!!...

Source: WHO (2005). The World Health Report 2005 – Make Every Mother and Child Count. Geneva, World Health OrganizationSource: for annual numbers : WHO: World Health Statistics 2009

Annually, 536,000 women die of pregnancy related

complications 99% in developing countries

(1 per minute)~ 1% in developed

countries

8

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

&Community Health Care

Worker

Enrolled nurses

Expert Patients

REGULATIONSupervision, Delegation,

Substitution,Enhancement, Innovation

Task shifting 0

9

Expanded Service Roles (ESR)(Example TS I)

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

Diagnostic, PrescriptiveCase Treatment and

Management Authority

Delegation or Supervision

Pre-service training coupled with additional in-servicetraining

Expanded Service Roles (ESR)

SOP include:

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

Orthopedics, Ophthalmology, Dermatology etc.

Reg

ula

tory

Fra

mew

ork

10

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

11

Expanded Services Role (ESR)TS III—TBA, 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

12

Scope of Practice & Competencies

Standards of Care

Standard Pre-ServiceEducation & Training

Licensing & Registration &

Certification

StandardIn-Service Training &

Certificate

Recruitment, Deployment, Promotion, Salary, &

Other HR Issues

Working Conditions

Supervision/Mentoring & Accountability

Health CareWorkers

Financing &Sub-national

Implementation

1

2

34

5

6

7

89

Professional Councils

MOH

Professional Practice Acts

Professional Councils,Professional Associations,

MOHNormative Bodies (WHO)

MOE, MOHTraining Institutions,

Professional Councils,Professional Associations

Professional 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

13

Types of Regulation

Laws and statutes

Regulations

Guidelines

General and specific maternal health care provider policies

Program guidance

14

Why Develop A Regulatory Framework?

To build national and international support and commitment

To ensure quality and safety in the delivery treatment, care and prevention while 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

15

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

16

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 areas—retention and motivation policies

17

Policies need to address interventions at needed levels

Regional Referral Hospitalsalso called

Tertiary Care Centers

Health Centers (Type A and B)also called

Primary (First)-Level Health Care Facilitiesor

Health Clinics

District Hospitalsalso called

Second-Level Health Care Facilitiesor

First-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

CONCENTR

ATE O

N THESE 3

18

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?

19

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