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 Health
The George Washington University

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 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

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 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

SOURCE: JLI 2004./ WHO 2006 World Health Report

 Maternal Mortality Ratio (per 100,000 live
births) and Regional Averages

EURO
27

EMR
AMR O SEARO
O 420 450
99 AFRO
900

WPR
The average global Maternal Mortality Ratio of 400 maternal death
per 100,00 live births in 2005 has barely changed since 1990. O
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Source: for Regional Averages : WHO: World Health Statistics 2009

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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
** > 35% receive no
are not universally available
Antenatal Care
and accessible

In d ire c t C a u s e s
He m o rrh a g e
20%
25%

O th e r D ire c t C a u s e s
8%

In fe c tio n
Un s a fe Ab o rtio n 15%
13%
** ~ 50% of deliveries unattended O b s tru c te d L a b o r ** ~ 70% receive no postpartum care
E c la m p s ia
by skilled provider 7 % during 1st 6 weeks following delivery
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Source: World health Report, 2005
1 2 %
Health Workers Save Lives

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 Too Many Preventable Deaths!!...

Annually, 536,000 women

die of pregnancy related
complications
99% in developing countries
(1 per minute)
~ 1% in developed
countries

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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 Task shifting III

Registered Nurses
(clinical officers, health officers) & nurse mid-wives

REGULATION Enrolled nurses

Doctors
Supervision, Delegation,
Substitution,
Enhancement, Innovation
Nursing
Assistants
&
Task shifting 0
Community
Specialized Physicians Health Care
Worker

Task shifting IV
Expert Patients

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 Expanded Service Roles (ESR)
(Example TS I)

Delegation or
Supervision
Regulatory Framework

Medical Doctor Non-physician Clinicians

(e.g. AMO, Clinical Officers, Health Officers)

Pre-service training
coupled
with additional in-
service
training

Expanded Service Roles Diagnostic, Prescriptive

(ESR) Case Treatment and
SOP include:
Management Authority
Medical care and management, OBGYN (C/S),
minor Surgery, Anesthesia,
Orthopedics, Ophthalmology,
Dermatology etc.

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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 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

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 Regulating HCWs and Who is Involved?
Professional Council, MOH,
MOF, Local Government, Other Health Care Providers
MOH, IMF, WB

Professional Practice Acts

9 Supervision/Mentoring
Decentralization Policy Financing &
8 & Accountability
Sub-national
MOL, ILO,MOH, Implementation
Professional Association, Professional
Local Government Councils
Scope of Practice &
Labor Policies 1 Competencies
Working Conditions
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Maternal Health
Public Service Treatment and Care
Agency, Policies & Guidelines MOH
Health Care
MOH,MOF, IMF,
Local Government, Recruitment, Deployment, Workers
Professional Association Promotion, Salary, & 2
Standards of Care Professional Councils,
6 Other HR Issues Professional Associations,
MOH
Normative Bodies (WHO)
Civil Service Policies

5 Standard 3
In-Service Training & Standard Pre-Service
4 Licensing &
Certificate Education & Training
Registration &
Certification

MOE, MOH
MOH. MOE, Training Institutions,
Training Institutions, Professional Councils,
Professional Councils Professional Associations
Professional Councils, MOH
Professional Associations

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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 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

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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 areas—retention and motivation

policies

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 Policies need to address interventions at needed levels

Regional Referral Hospitals

also called
Tertiary Care Centers

District Hospitals
also called
Second-Level Health Care Facilities

3
or

E
ES
First-Referral Level Facilities

TH
N
O
Health Centers (Type A and B)

E
also called
AT
Primary (First)-Level Health Care Facilities
TR

or
EN

Health Clinics
NC
CO

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
 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 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

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