A. Metin Gülmezoglu World Health Organization

1. Optimizing the delivery of key interventions to attain MDGs 4 & 5through task-shifting(Optimize4MNH) A. Metin GülmezogluWorld Health Organization

2. Outline • Background to the guideline • WHO Guideline development standards • Process to date

3. Optimizing the delivery of key interventions for MNH • Current controversies in the field of maternal and newborn health where WHO guidance may be helpful • Misoprostol use by community health workers • TBA training to improve maternal and newborn outcomes • Nonphysician clinicians performing caesarean sections • MgSO4 use by midwives • Contraceptives by lay health workers

4. Relevant publications and meetings • World Health Organization (2010). Increasing access to health workers in remote and rural areas through improved retention. Global policy recommendations. Geneva, Switzerland: WHO. Available at http://www.who.int/hrh/retention/guidelines/en/index.html. • World Health Organization (2008). Task shifting: rational redistribution of tasks among health workforce teams : global recommendations and guidelines. Geneva, Switzerland: WHO. Available at: http://www.who.int/hiv/topics/systems/health_workforce/en/ • World Health Organization. (2008). International conference on task shifting (Addis Ababa Declaration 2008): Geneva, Switzerland: WHO. Available at http://www.who.int/healthsystems/task_shifting/Addis_Declaration_EN.pdf • Bhutta, Z.A., Lassi, Z.S., Pariyo, G., & Huicho, L. (2010). Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems. Geneva, Switzerland: WHO & GHWA. Available at http://www.who.int/workforcealliance/knowledge/publications/alliance/Global_CHW_web.pdf

5. The WHO Guideline Development Standards • WHO has internal regulations and standards for developing guidelines: WHO Handbook for guideline development • WHO guideline review committee (GRC) monitors the guideline development process and ensures that the relevant regulations and standards are applied proposal content development technical unit  GRC  technical unit GRC  final approval

6. The Guideline Development Process • the process includes: • (i) identification of priority questions and critical outcomes; • (ii) retrieval of the evidence; • (iii) assessment and synthesis of the evidence; • GRADE and DECIDE frameworks • (iv) formulation of recommendations; • (iv) planning for dissemination, implementation, impact evaluation and updating.

7. Primary objective • To identify and make recommendations on cadre(s) of workers who can increase access to effective practices in a safe way • In other words, we are interested in both task-shifting and expanding the roles of cadres to optimize access

8. Chronology • Mid-2010: Support secured to work on the guideline • Late-2010: The WHO internal working group on the Opt4MNH guideline established • December 2010: Guideline scoping meeting • January 2011 to date: Evidence synthesis, quality assessment • Mid 2010 to April 2012: Meeting within WHO WG every 3-4 months, two technical meetings on qualitative reviews

9. When • Who • What • Where Scoping challenge: Going vertical or horizontal? • Regulatory frameworks • (legal issues, training, supervision, career paths, retention, …)

11. Guideline questions • The focus of the recommendations is on cadre + intervention • We are NOT addressing the questions at the system level • We are NOT recommending the initiation or abolition of any cadre programme • We are NOT comparing task shifting to a particular cadre with another type of intervention that organizes care in a different way (e.g. maternity waiting home) • We are NOT addressing teams of cadres delivering interventions • We are aware that asking the questions in this way does not address the whole problem particularly for national policy-making but, that was the only practical way we could see and agreed upon at the scoping meeting!

12. Guideline Steering Group WHO internal working group • Health Systems / Human Resources for Health • Carmen Dolea • Annette Mwansa Nkowane • HIV/AIDS • Eyerusalem Kebede Negussie • Maternal Newborn, Child and Adolescent Health • Rajiv Bahl • Blerta Maliqi • Matthews Mathai • Annie Portela • Nutrition • Luz Maria De-Regil • Juan Pablo Pena-Rosas • Reproductive Health and Research • João Paulo Dias De Souza • Mario Festin • A. Metin Gülmezoglu • Mario Merialdi • Lale Say • Interns (Stephanie Polus, Watananirun Kanokwaroon, • Joshua Vogel, Fabiola Stollar) • Cathy Kiener • Alliance for Health Systems and Policy Research • Taghreed Adam • Nhan Tran • Global Health Workforce Alliance • George Pariyo Technical working group • Norwegian Knowledge Centre • Claire Glenton • Simon Lewin • Sarah Rosenbaum • Jenny Moberg • Unni Gopinathan • Elin S Nilsen • Qualitative reviews group • Jane Noyes • Chris Colvin and the SA team • Arash Rashidian and the Iran team • Chris Morgan • Neil Pakenham-Walsh • Onikepe Owolabi   • Effect reviews • Rajesh Khanna • Zohra Lassi • Olufemi Oladapo • Stephanie Polus • Watananirun Kanokwaroon • Priya Miriyam Lerberg

13. Thanks