Seble Frehywot MD, MHSA Assistant Research Professor of Health Policy and Global Health

1. Human Resources for Maternal Health and Task-ShiftingJanuary 6th, 2010Woodrow Wilson CenterWashington, DC Seble Frehywot MD, MHSA Assistant 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 < 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

4. Maternal Mortality Ratio (per 100,000 live births) and Regional Averages EURO 27 EMRO 420 AMRO 99 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. Source: for Regional Averages : WHO: World Health Statistics 2009 WPRO 82 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

5. Global Causes of Maternal Mortality and the Need for Skilled Workforce • **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 Source: World health Report, 2005

6. Health Workers Save Lives

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

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

9. Expanded Service Roles (ESR)(Example TS I) Delegation or Supervision Medical Doctor Non-physician Clinicians (e.g. AMO, Clinical Officers, Health Officers) Pre-service training coupled with additional in-service training Regulatory Framework 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

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

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 Hospitals also called Tertiary Care Centers District Hospitals also called Second-Level Health Care Facilities or First-Referral Level Facilities CONCENTRATE ON THESE 3 Health Centers (Type A and B) also called Primary (First)-Level Health Care Facilities or Health Clinics Health Posts Also called Health Houses SOURCE: WHO (2005): WHO Recommendations for Clinical Mentoring to Support Scale-up Of HIV Care, Antiretroviral Therapy and Prevention in Resource-Constrained Settings.

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