70385 Human Resources for Maternal and Neonatal Health: A review of policy in South Asia and Sub Saharan Africa Prepared for Health, Nutrition, and Population, The World Bank By Sabina A. Haberlen, MSc September 2008 Table of Contents APPENDIX: SUMMARY TABLE HRH FOR MATERNAL AND NEONATAL HEALTH.......................... 2 1. INTRODUCTION AND OBJECTIVES .......................................................................................................... 1 2. WHY EXAMINE HRH POLICY FROM A MATERNAL AND NEONATAL HEALTH LENS?............ 2 A RENEWED FOCUS ON THE HRH CRISIS ................................................................................................................ 2 TYPES AND CHARACTERISTICS OF HRH PROBLEM ................................................................................................. 2 GROWING ATTENTION TO HRH FOR MATERNAL AND NEONATAL HEALTH ........................................................... 3 FACILITIES AND SKILL-SETS TO DELIVER MATERNAL MORTALITY INTERVENTIONS ............................................... 3 FACILITIES AND SKILL-SETS TO DELIVER NEONATAL HEALTH INTERVENTIONS...................................................... 4 EVIDENCE BASE ON HRH FOR MATERNAL AND NEONATAL HEALTH ................................................................... 5 3. WHAT ARE COUNTRIES DOING TO OVERCOME THE HR SHORTAGE FOR MATERNAL AND NEONATAL HEALTH? ........................................................................................................................................ 5 METHODS .............................................................................................................................................................. 5 FINDINGS ............................................................................................................................................................... 6 4. WHAT LEVEL OF EVIDENCE EXISTS FOR HRH POLICIES FOR MATERNAL AND NEONATAL HEALTH?................................................................................................................................................................ 8 5. DISCUSSION AND CONCLUSION .............................................................................................................. 19 APPENDIX: SUMMARY TABLE HRH FOR MATERNAL AND NEONATAL HEALTH 1. Introduction and Objectives The critical state of the health workforce in less economically developed countries received renewed attention from governments, the international development community, professional associations, and research institutions in early 2000. Human resources for health (HRH) are a necessary input to reducing maternal mortality, an international priority and Millennium Development Goal (MDG). However, while the safe motherhood movement recognizes the role of human resources in reducing maternal deaths and disability, it less often addresses the specific HRH policies needed to produce the quantity, quality, and distribution of these health workers. In order to inform current and future reproductive health projects at the World Bank, more data was needed on current practices to address the human resource crisis in maternal health. Thus in May 2007, the Health, Nutrition, and Population Division commissioned a desk review of the grey and published literature on HRH policies with relevance for maternal health. Given the close relationship between improving maternal and neonatal health, human resources that overlap with neonatal health are also considered. The review was limited to the regions with the highest burden of maternal and neonatal mortality, South Asia (SA) and Sub Saharan Africa (SSA). Further, the review was limited to supply-side issues of HRH. The objectives were to: • Generate a bibliography on HRH for maternal and neonatal health • Identify HRH policies that SSA and SA countries have implemented and assess their implications for maternal and neonatal health (i.e. likely to have direct effects, indirect effects, or no effects) via a literature review • Summarize what evidence if any exists on the process or outcome evaluations of these policies This document is organized into five sections. A companion bibliography document is also available. The background and rationale for considering HRH policies specific to maternal and neonatal health are described in Section Two. Section Three presents selected findings on HRH policies for maternal and neonatal health in South Asia and Sub Saharan Africa, with the full results table presented in the Appendix. It includes a brief description of the policy, its expected effect on maternal and/or neonatal health, and the level of health care system in which it operates. Section Four describes the process taken to generate the policy options table. The policy options table summarizes the process, outcome, and economic evaluation for five selected HRH policies. Finally, Section Five synthesizes the findings and discusses gaps and opportunities for HRH policies for maternal and neonatal health. 1 2. Why examine HRH policy from a maternal and neonatal health lens? A renewed focus on the HRH crisis While human resources for health have been a constraint for many decades across most of the less economically developed countries, recent systematic assessments have declared it a state of crisis1-3. The Joint Learning Initiative was seminal in generating evidence and attention to these issues4. The 2006 World Health Report focused on constraints and opportunities for HRH, as have a number of initiatives including the Capacity Project and the Global Health Workforce Alliance5. Medical journals have devoted issues to the topic6, and Human Resources for Health is an open-access online peer-reviewed journal dedicated exclusively to issues relevant to the health workforce. The World Bank has undertaken a number of studies and projects to support good HRH policy, particularly in the Africa Region. The current attention and funding available for human resources is an opportunity to improve health outcomes, including maternal and neonatal health, through effective policies and programs. Types and characteristics of HRH problem The cause and nature of the HRH problem varies by context, but useful typologies have been developed based on commonalities across countries. Zurn and colleagues identify four categories of health workforce imbalance: 1) profession/specialty, which includes the ratio of professions to one another and shortages of particular professions or specialists, 2) geographic, where the health workforce is skewed towards urban centers and wealthy areas, 3) gender imbalances in the workforce, and 4) institutional/services imbalance between various facilities such as private and public, and supply differences between particular services7. Sub-optimal training, skills, motivation, and performance are also of major concern. Each type of imbalance impacts maternal and neonatal health. The shortage of health professionals with midwifery skills is a major challenge for most countries in Sub Saharan Africa and South Asia. There is also a shortage of health professionals trained to perform emergency obstetric surgery and to administer the anesthesia required for surgeries in many countries in the regions. The shortage of skilled attendants is usually most severe in rural areas, reflecting a geographic imbalance in the health workforce. Since the majority of the population in Sub Saharan Africa and South Asia live in rural areas, the geographic imbalance has a large impact on availability of maternal care. Emergency obstetric care (EmOC) facilities may also be maldistributed, at extensive distances from some communities. With more than 60% of maternal deaths occurring within 48 hours after delivery8, delays in reaching the health care facility have deadly consequences for rural women. The gender distribution of the health workforce is of particular concern for maternal and neonatal health, since women may prefer or be culturally restricted to female providers for care7. While nurse midwives are most often females, managers, physicians, and obstetrician-gynecologists are generally male in Asia and Sub Saharan Africa. Countries such as Pakistan have the dual 2 conundrum of high demand for and low supply of female providers, due to the same underlying cultural constraints9. Under-representation of ethnic groups could have similar implications for access to and demand for care. Countries may also have imbalances between 1) public and private sector institutions and 2) services provided by cadres. The private sector, international NGOs, and faith-based institutions attract health workers away from the public sector in many African and South Asian settings by creating “two tiers of salary�3. While the ideal public-private health sector mix differs by context, imbalances occur if services are unaffordable to the poor. The services provided by health workers may also impact maternal and neonatal health. For example, the expansion of postnatal visits into the job description of Lady Health Workers in Pakistan may improve neonatal health. In contrast, India’s Auxiliary Nurse Midwife cadre’s maternal health responsibilities were ended in 1966 in order to address other health priorities, such as family planning and immunizations10. The net effect of the health worker shortage and maldistribution on maternal and neonatal health is that many women deliver without an attendant with midwifery skills and without access to emergency obstetric care, contributing to the more than 529,000 maternal deaths each year11. Growing attention to HRH for Maternal and Neonatal Health The greatest HRH focus of the Safe Motherhood community has been on skilled attendance at delivery. The 1997 Technical Consultation on Safe Motherhood promoted skilled attendance at birth, combined with access to transportation in the event of emergency, as the intervention most likely to reduce maternal mortality12. The current focus on increasing facility-based deliveries13 requires a skilled attendant at birth as well as access to the necessary specialists and facilities for obstetric emergencies. The maternal and neonatal health field has recognized human resource issues beyond the call for skilled attendance at birth. The World Health Report in 2005, Make Every Mother and Child Count, cited building adequate human resources as the first step towards reducing maternal and neonatal mortality, and devoted a chapter to HRH issues such as remuneration and incentives to improve retention. In order to have adequate HRH capacity to reduce maternal and neonatal mortality by 2015, WHO estimated that 334,000 additional midwives need to be trained and that 140,000 health workers and 27,000 physicians currently providing obstetric care need to have their skills upgraded11. The Averting Maternal Death and Disability (AMDD) program at Columbia University has taken a leading role in exploring HRH policies of relevance to maternal and neonatal health. They summarized country policies to increase the number of health providers trained to administer anesthesia for emergency obstetric surgery14 and are currently documenting task-shifting for maternal health in three African countries15. Facilities and skill-sets to deliver maternal mortality interventions The majority of maternal deaths are due to four direct causes: post-partum hemorrhage, obstructed labor, sepsis, and eclampsia, which require special management11. Therefore, the health of a mother and her neonate depend on both a skilled attendant at birth and a functioning referral system with access to emergency obstetric care (EmOC). Basic EmOC includes the capacity to deliver antibiotics and oxytocic drugs by injection or infusion, administer 3 anticonvulsants for pre-eclampsia and eclampsia, perform manual removal of retained matter, and perform assisted vaginal delivery16. Comprehensive EmOC supplements the basic package with the capacity to perform surgery and blood transfusions16. Skilled attendants with adequate facilities and supplies can be trained to deliver most Basic EmOC functions. However, comprehensive EmOC requires cadres trained to perform surgery and administer anesthesia. Despite the high-visibility focus on increasing skilled attendance at birth since 1997, Stanton notes that the definition of a skilled attendant was slow to emerge due to a lack of consensus in the Safe Motherhood community17. The joint statement by the World Health Organization (WHO), International Confederation of Midwives (ICM), and International Federation of Gynecology and Obstetrics (FIGO) defines a skilled attendant as “an accredited health professional — such as a midwife, doctor or nurse — who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns�18. Therefore, the definition excludes non-medical community health workers, traditional birth attendants, and nurses and doctors without training in midwifery. The WHO concludes that these non-skilled care providers “can deliver parts of the interventions known to be effective but only if they are supported and supervised by providers with midwifery skills�19. There is not good evidence that training traditional birth attendants (TBAs) has reduced maternal mortality. However, small trials have shown promise for the prevention and treatment of post- partum hemorrhage with misoprostol, delivered by a traditional birth attendant, auxiliary nurse midwife, or paramedical worker20-23. Walraven and Weeks suggest that TBAs could also be trained to counsel women about and provide iron and folate supplements in the antenatal stage, conduct post-partum home visits to monitor sepsis and counsel women on breastfeeding and hygiene, and provide referrals and encourage care-seeking24. Campbell and Graham’s table of evidence-based interventions to improve maternal and/or neonatal health included a limited number of interventions that could be delivered effectively by TBAs. They could advise women on care-seeking, planning for emergencies, and breastfeeding and neonatal warming; provide hygienic cord care; and detect and refer delivery complications, etc. 13. Facilities and skill-sets to deliver neonatal health interventions It is estimated that the primary direct causes of neonatal death are infections (36%), preterm birth (28%), asphyxia (23%), and congenital abnormalities (7%)25. Neonatal mortality is fundamentally linked to the mother’s health status and medical care, from nutrition and antenatal care during pregnancy, to the management of labor, to care and breastfeeding in the postpartum period. However, in contrast to the interventions required to prevent maternal mortality, significant causes of neonatal death including asphyxia and sepsis can be prevented by a non- skilled attendant outside of a health facility setting. Bang and Bang and colleagues demonstrated declines in neonatal mortality from sepsis26, birth asphyxia27, and low birth weight-related vulnerability28 in their field trials in rural Gadchiroli, India, through home-based care delivered by community health workers, traditional birth attendants, and mothers. In the Lancet series on Neonatal Survival, Darmstadt and colleagues concluded that while 18- 37% of neonatal deaths could be averted through home and community level-interventions, 4 strengthening the health systems to ensure skilled attendance at birth and access to emergency obstetric care is necessary to reduce neonatal deaths by 50%29. Meeting the human resources required to prevent maternal mortality will reduce neonatal mortality; hence our rationale for combining the two outcomes. Evidence Base on HRH for Maternal and Neonatal Health The evidence for an increase in skilled attendance at birth to reduce maternal mortality includes ecological, observational, and historical case studies30. Anand and Baernighausen found that at the national level, higher health worker density was associated with lower maternal mortality and neonatal mortality rates, when controlling for socioeconomic indicators30. A smaller but significant effect was also noted on neonatal health, which is consistent with the greater dependence of maternal mortality prevention on highly skilled health professionals30. An analysis of Demographic and Health Surveys (DHS) from 27 African countries found that neonates born to mothers with antenatal care and a skilled attendant at birth had half the risk of death as those without11. Graham and colleagues estimated that between 16-33% of maternal deaths could be prevented by skilled attendance at birth in an enabling environment that has the proper equipment, supplies, pharmaceuticals, and access to transportation8. Case studies of countries that have successfully reduced their maternal mortality rates, such as Indonesia, Sri Lanka, and Egypt, cite the role of adequate HRH as a contributing factor. However, to our knowledge there is no review of contemporary HRH policies related to maternal and neonatal health. The next section describes the methods and findings from the review of HRH policies in SSA and SA, and their implications for maternal and neonatal health. 3. What are countries doing to overcome the HR shortage for maternal and neonatal health? Methods We reviewed the published and grey literature on policies and programs to improve human resources for maternal and neonatal health between May and June of 2007, and updated in April 2008. A purposive list of organizations, authors, and journals involved in HRH and/or maternal and neonatal health was developed. These organizations’ websites were searched for grey literature pertaining to human resources. Additional documents were identified by hand- searching the bibliographies and links on organization websites. Peer-reviewed articles were identified through the PubMed database using a series of search terms "maternal health services", "maternal welfare", “maternal health� and the MESH search terms "health manpower", "health personnel", or "allied health personnel". The summary table (Appendix) is the result of this purposive search rather than of a systematic review of the literature. Due to time and budgetary limitations, we did not seek information from country representatives. The summary table follows Egger and colleagues’ typology of HRH policy: the rational production of health workers, the rational utilization of health workers, and compensation and management of health workers31. Tracking these policy categories to the types of underlying workforce challenges, policies for rational production would involve training the right numbers of various levels of health workers and investing in academic training institutions to address the 5 imbalance of professions/skills. Rational production policies may also increase the number of female health workers to address a gender imbalance. Rational utilization policies aim to increase the number of health workers in rural and underserved areas to correct for geographic imbalances. Examples include providing scholarships for members of rural communities to study to be health professions, requiring a time period of service in underserved areas after medical training, or providing benefits to make rural postings more attractive. Policies for compensation and management of health workers may aim to increase worker satisfaction, quality, and retention in the public sector, thereby reducing an institution/services imbalance. They may also aim to increase efficiency, quality, or cost-effectiveness of the health system. This summary further distinguishes between rational utilization policies with professional workers such as physicians, nurses, midwives, and other formalized cadres, and rational utilization that builds on non- professional workers such as community health workers or traditional birth attendants. The summary also includes historical information related to human resources for health in countries that improved maternal health as well as a category documenting failed HRH initiatives. Overlap between categories exists; some policies address more than one underlying HRH imbalance just as some HRH imbalances could be addressed with multiple policy categories. For each policy or program, the three authors determined whether it was expected to have a direct, indirect, or no effect on maternal and neonatal health. HRH policies with a direct effect include those that specifically target health workers with midwifery or neonatal care skills, or auxiliary skills necessary to deliver comprehensive emergency obstetric care. Other HRH policies would strengthen the health workforce generally, and are thought to indirectly benefit maternal and neonatal Levels of Health Care Provision health by increasing the supply of skilled attendants Community-based primary health care: “The first level contact 32 with people taking action to improve health in a community� without and other workers involved a physical infrastructure. This includes health care provided within the in emergency obstetric care. household, through unskilled community health workers, and through In cases of disagreement, it skilled workers. was further discussed until a Facility-based primary health care: “The first level contact with unanimous decision was 32 people taking action to improve health in a community� with a reached. physical infrastructure. Includes basic emergency obstetric care facilities (bEmOC) that provide some of the signal functions Furthermore, the policies Secondary health care: “Specialized ambulatory medical services and were classified based on the commonplace hospital care (outpatient and inpatient services). Access health system level they 32 is often via referral from primary health care services� . Includes would affect: community- referral centers such as comprehensive obstetric care facilities (cEmOC) based primary health care, and hospitals. facility-based primary health care, or secondary health care. We distinguish between primary health care in the community and primary health care facilities based on infrastructure. Findings While few documents focused squarely on HRH for maternal and neonatal health, general HRH documents often referenced maternal and neonatal health skill-sets, including delivery care and the provision of emergency obstetric care. Conversely, many maternal and neonatal health 6 documents included sections about human resources. The full table of results is attached in the Appendix. Most documented policies and programs were forms of rational utilization. Specifically, there were many examples of delegation of skills and task-shifting, as well as utilization of community health workers. Delegation of surgical skills to general physicians with some additional training is practiced in Nepal, Bangladesh, and Pakistan33. Nurses have been the backbone of health systems in Africa, and there were many examples of formal and informal delegation of maternal health related tasks from physicians. Midwives and nurses may perform all of the basic emergency obstetric care functions in Tanzania34, Ethiopia34, Nepal34, Zambia35, and rural Ghana35. Countries with severe physician and specialist shortages, such as Burkina Faso34, Mozambique36, and Malawi37, authorize mid-level cadres to perform emergency obstetric surgeries. The training, scope of work, title, and regulation of these cadres vary by country i , and in general their training is not transferable to other countries. This is considered an advantage; a means to stem the international migration of such health professionals compared to physicians and nurses. Generally, there is little evaluation of the effectiveness of such cadres on maternal and neonatal health outcomes. Many countries utilized community-based health workers, such as the Lady Health Workers in Pakistan, to provide family planning and other maternal and neonatal health services9;38. These cadres are often female to meet population demand. Despite the limited evidence of effectiveness of policies that involve traditional birth attendants, the social role of the TBA and shortage of skilled attendants in some areas has led to continued reliance on TBAs in rural areas. Reports of successful and unsuccessful TBA-based interventions were included in the review. Management and incentives aim to improve performance and retention. In countries such as the Philippines31 and Malawi39, salaries were increased. The Uganda Health Services offered an incentives package that included lunch40. Botswana implemented a Management Information System for all nurses and midwives in the country, in order to better allocate resources31. No management and incentives policies specific to maternal and neonatal health functions were identified. Examples of rational production are scarce, possibly because of a publication bias towards novel policies, such as incentive programs or new cadres of health workers. Simply training more health workers might not have prompted documentation, and without requesting information from countries such policies could easily be overlooked. Nevertheless, the review captured rational production strategies, including the development of an Anesthesia Assistant course in Nepal14, Guinnea-Bissau’s policy to reduce the number admitted to medical school in order to increase the admissions for lower level health professions31, and the Philippines policy to train and place more midwives31. HRH policy categories vary with respect to required resources, lag time, and perceived permanence. Training additional health professionals will take time to affect the workforce, while other strategies such as recruitment incentives or short-course training will generate effects more rapidly. Policies vary on their planned permanence as well. Some policies, like Nepal’s i Dovlo 2004 provides an excellent review of mid-level providers in Africa, full reference in bibliography. 7 training for anesthesia assistants, are undertaken on a short-term basis until adequate anesthesiologists are available, while others, such as increasing salaries to more competitive levels, are intended to be sustained changes. It is likely that both immediate and long-term investments will be required to meet the Millennium Development Goals to reduce maternal and newborn mortality. 4. What level of evidence exists for HRH policies for maternal and neonatal health? As summarized in the Appendix, countries have implemented a range of policies to overcome health worker shortages and imbalances. However, the evidence of the effects of these policies in SSA and SA are weak. A recent analysis of the effectiveness of HRH policies included only eight reviews with a low or middle income country41. Therefore, the findings may be of limited transferability to low income countries. Recognizing that every country faces unique contextual factors but that many have common HRH challenges, we compiled the documented evidence on five selected country policies into a policy options table, Table 1. It represents a first step towards building evidence of the effect of HRH policies for maternal and neonatal health in the regions with the highest rates of maternal and neonatal deaths. Policies from five countries were selected as examples of HRH policy options. Sri Lanka and Botswana were identified for rational production, and Mozambique, Nepal and Pakistan were selected as examples of rational utilization policies. Since no evidence was found on the effects of HRH compensation and management policies on maternal or neonatal health, these approaches are not included. Policies were chosen in order to represent a range of options and were based on the availability of documentation of process or outcome. The policies cited for Sri Lanka and Botswana are the HRH components of comprehensive maternal health policies with good outcomes. The policies in Mozambique and Nepal have been recognized as promising practices for intermediate outcomes, though not for reducing maternal mortality. Pakistan was chosen to represent a policy that relies on community health workers. In sum, the policies highlighted in the following table are the best-documented approaches rather than the definitive best practices. Most evaluation of the five policies used case study methods, including key informant interviews and retrospective observational data. The most rigorous study designs were pre-post and none were evaluated as randomized trials. Therefore, in all cases it was impossible to separate the human resources component from other policy and contextual factors that could affect maternal and neonatal outcomes. Moreover, workers require an enabling environment with referrals, transportation, and infrastructure to be effective. Given these limitations and the difficulty in measuring changes in maternal mortality, the proportion of births with a skilled attendant is a good substitute endpoint with a direct causal link to the health worker. This outcome is used to measure progress towards the MDG, and is thus readily available. In addition to outcomes, we also searched for economic and process evaluation. Process indicators and intermediate outcomes of the specific HRH policies included surgical outcomes for the surgical technicians in Mozambique, numbers of health workers in the field, and retention rates. 8 Table 1: Policy Options for Human Resources for Maternal and Neonatal Health Country and HR Policy Action Other Relevant Regional Process Economic Outcome Underlying Policy Action distribution Evaluation Evaluation Evaluation Problem effects Sri Lanka Rational -Government -Reached -4600 Public - Only -Sri Lanka -Maldistribution Production: subsidized multiple Health between .14 to has achieved of skilled health Produce Large transport fees geographic Midwives .31 percent of a continuous professionals, Number of between PHC and locations and deployed in the GDP was decline in with shortages in trained midwives referral sites for ethnic groups 2002 and as of used for the MMR rural areas, and obstetric 1996 there maternal since 1947, less access to Sri Lanka had a emergencies43 were 6745 health care43 down to 27 EmONC in rural longstanding midwives in in 199243 areas. tradition of training -Increased access total professional to free community (including -No cost- -The -Need for strong midwives, and they heath services42 those with effectiveness proportion referral systems were the backbone higher level studies found of births with fewer from which efforts -Offered more training) 42 with a barriers to improve the obstetric health skilled health system for services42 -Case studies attendant -MMR as high as maternal health have identified increased 1,660 in 194742 were made -Utilizing a high-level from 27% in possible16;42-44 Sri monitoring system commitment to 1939 to 89% Lanka has also to measure reducing in 199543 increased the progress42 maternal number of mortality and physicians and -Sri Lanka has to access to obstetricians decreased the healthcare as trained43 salaries of health factors that workers, which facilitated the -Training: for has decreased reduction43 Public Health motivation43 Midwives, 18 (though evidence -Midwives are month training of a negative effect valued and course; for Public on quality or well respected Health Nursing health outcomes is in the Sister 4 years of not apparent) communities nursing training, 6 they serve43 mos of midwifery training, and 6 mos field work -Recognition: Midwifery was registered profession since late 19th century42 9 Political Economic Context Sri Lanka Political: The government is concerned with equity and social welfare, and has provided universal access to health care and education43. Despite political unrest in some provinces, the government has been fairly stable and made continuous investments in health and social welfare. Maternal health has been identified as a government priority, which has been sustained over time. Professional: Midwives have been historically important parts of the health care system and their role has not been met with resistance by physicians or obstetricians42. Legal/Regulatory: Midwives must be registered and have been since 1887 Gross National Income per capita; purchasing power parity (i) $5,010 (2006) Maternal mortality ratio (MMR) (ii) 27 per 100,000 live births (1992) Percent of births with skilled attendant (ii) 89% (1995) Notification of Maternal Deaths (ii) Yes Costed plan for MNH (ii) Data not available Availability of EmOC (ii) Data not available Midwives recognized (ii) Yes Non-physicians authorized in EmOC surgery (iii) Data not available Physician density (iv) 0.55 per 1000 (2004) Midwife density (iv) 0.16 per 1000 (2004) Nurse density (iv) 1.58 per 1000 (2004) Health worked density (combined) (ii) Data not available Per person health expenditure (international dollars) (i) $121 (2003) Out of pocket health expenditure (ii ) Data not available Percent at less than $1 per day (i) 5.6% (2008) Percent rural (i) 84.8% (2003-05) Life expectancy at birth (iv) 71 (2004) i. World Bank World Development Report 2008 ii. Millennium Countdown Working Group, 2008 iii. Kowalewski & Jahn, 2001 iv. WHO World Health Report, 2006 10 Table 1: Policy Options for Human Resources for Maternal and Neonatal Health, cont Country and HR Policy Action Other Relevant Regional Process Economic Outcome Underlying Policy Action distribution Evaluation Evaluation Evaluation Problem effects Botswana Rational -Improved referral -Distribution -562 midwives -None found -Skilled -Shortage of Production: protocols and paid of health were trained attendant at health workers investment in transportation services was between 1994 delivery and of those with midwives plans for obstetric relatively and 200242, increased specialist skills -Increased the emergency42 good prior to and the from 66% in for obstetric care number of the program government 1984 to 87% midwives trained -Developed a planned to in 199642 to and improved the strong health increase that 97% in quality of training system with good number. 200045 regional access42 -Training: -68 midwives Midwifery training -Protocols for and 12 medical is 18 months; there maternal care and officers were 3 midwifery referral are received in- training schools in practiced and an service 200242. obstetric record training on assists with life-saving -Continuing consistency of obstetric skills education: care42 between 1994- Botswana began an 95 in-service training -Information, on life-saving Education, and obstetric skills for Communication midwives and (IEC) Campaign physicians in was launched to 199442 increase demand for maternal health services42 11 Political Economic Context Botswana Political: As a stable democracy with rich natural resources, the government of Botswana has invested in health and social welfare, with public sector spending at 30% of the GDP. Investments in maternal and reproductive health increased in the 1970s, though indicators for maternal health were poor in the 1980s. The MOH researched the causes of maternal deaths in the country and developed a Safe Motherhood Program to address the causes and reduce maternal mortality. Professional: Nurses and midwives are the backbone of the health systems. Botswana has no medical school. Legal/Regulatory: Midwives are trained in life-saving skills and may co-manage emergency obstetric surgeries with physicians42. Gross National Income per capita; purchasing power parity (i) $12,250 (2006) Maternal mortality ratio (MMR) (ii) 380 per 100,000 live births (2005) Percent of births with skilled attendant (ii) 97% (2000-06) Notification of Maternal Deaths (ii) No Data Available Costed plan for MNH (ii) No Data Available Availability of EmOC (ii) No Data Available Midwives recognized (ii) No Data Available Non-physicians authorized in EmOC surgery (iii) Yes Physician density (iv) 0.4 per 1000 (2004) Midwife density (iv) No Data Available Nurse density (iv) 2.65 per 1000 (2004) Health worked density (combined) (ii) 3.1 per 1000 (2004) Per person health expenditure (international dollars) (i) $504 (2008) Out of pocket health expenditure (ii ) 10.4% (2008) Percent at less than $1 per day (i) 23.5% (1993) Percent rural (i) No Data Available Life expectancy at birth (iv) 40 (2004) i. World Bank World Development Report 2008 ii. Millennium Countdown Working Group, 2008 iii. Kowalewski & Jahn, 2001 iv. WHO World Health Report, 2006 12 Table 1: Policy Options for Human Resources for Maternal and Neonatal Health, cont Country and HR Policy Action Other Relevant Regional Process Economic Outcome Underlying Policy Action distribution Evaluation Evaluation Evaluation Problem effects Mozambique Rational -MOH developed -Between 83- -Program has -$144,723 -No Shortage of utilization: Task a policy to 90% of trained 61 estimated significant health shift emergency decrease maternal surgical surgical start-up costs difference in professionals obstetric care to mortality, which technicians technicians for the post- skilled to less-skilled cadres included HR are posted to (from 1984 to program46 operative perform surgery components such the district 2007)46 outcomes of after Mozambique began as training in Safe (rural) -Total training caesarian independence, training of a mid- Motherhood for hospitals36;47 -Of the 12,178 expenses are sections particularly in level cadre, the Maternal and obstetric $19,464 per performed rural areas surgical technicians Child Health - After 7 surgeries surgical by surgical in 1984. 46 Nurses and years, 90% performed in technician vs technicians High maternal physicians of surgical 2002, 57% $74,129 per compared to mortality -Training: technicians were by obstetrician46 obstetricians 48 (estimated 1000 candidates require are still at surgical per 100,000 live mid-level health rural post, technicians (as -Cost per births)36 training (at least a compared to were 92% of obstetric -Of 10,258 medical assistant) 0 surgeries at surgery is surgeries and several years physicians36 district $39by (not limited of practice before hospital surgical to obstetric) admission. level)36 technician vs. performed Training is 2 years, $144 by by surgical followed by a 1 -Other health obstetrician46 technicians, year internship and workers have post- final exam46 positive operative attitudes mortality is -Recognition: New towards the .1% for policy to extend surgical elective training of surgical technicians, surgeries technicians, though the and .4% for leading to an surgical emergency academic degree, technicians surgeries49 but as of 2007 the require greater career pathway was formal ill-defined47 recognition and motivation3 -Health workers report that having surgical technicians available at rural facilities reduces the burden of referrals on both the family and secondary care facilities47 13 Political Economic Context Mozambique Political: Based on several publications which document the history of the surgical assistant program, the effort to train mid-level providers to perform surgery began in 1984 to address the shortage of physicians and surgeons after independence and during the civil war. The post-war government in the early 1990s faced many challenges and competing priorities50. Since the early 2000s, the government has shown commitment to reducing maternal mortality through a multisectoral plan to reduce transportation barriers and increase access to emergency obstetric care50. Professional: Cumbi and colleagues noted that initially, there was some resistance among physicians and nurses to the cadre of surgical officers, though it is not mentioned whether there was official action taken by their professional organizations47. There is a plan to transition the surgical assistant training into an academic degree program47;51. Legal/Regulatory: Surgical assistants are legally permitted to perform surgeries. However, midwives are not registered and there is much regulatory change needed to improve human resources for maternal and neonatal health. Gross National Income per capita; purchasing power parity (i) $1,220 (2006) Maternal mortality ratio (MMR) (ii) 520 per 100,000 live births (2005) Percent of births with skilled attendant (ii) 48% (2000-06) Notification of Maternal Deaths (ii) Part (2008) Costed plan for MNH (ii) Part (2008) Availability of EmOC (ii) Data not available Midwives recognized (ii) Yes (2008) Non-physicians authorized in EmOC surgery (iii) Yes (2001) Physician density (iv) 0.03 per 1000 (2004) Midwife density (iv) 0.12 per 1000 (2004) Nurse density (iv) 0.21 per 1000 (2004) Health worked density (combined) (ii) 0.40 per 1000 (2004) Per person health expenditure (international dollars) (i) $42 (2008) Out of pocket health expenditure (ii ) 12.2% (2008) Percent at less than $1 per day (i) 36.2% Percent rural (i) 66.3% (2003-05) Life expectancy at birth (iv) 45 (2004) i. World Bank World Development Report 2008 ii. Millennium Countdown Working Group, 2008 iii. Kowalewski & Jahn, 2001 iv. WHO World Health Report, 2006 14 Table 1: Policy Options for Human Resources for Maternal and Neonatal Health, cont Country and HR Policy Action Other Relevant Regional Process Economic Outcome Underlying Policy Action distribution Evaluation Evaluation Evaluation Problem effects Nepal-Shortage Rational -Medical doctors -Majority (31 -40% of all -None found -An of professionals utilization: Task are trained to of 41) AA surgeries evaluation trained to shift anesthesia to perform work outside performed are found that administer mid-level cadres emergency of the capital emergency 80% of the anesthesia for obstetric care33 city14 obstetric at a AAs were surgery, Nepal developed sample of skilled in including major an Anesthesia hospitals being providing obstetric surgery Assistant (AA) evaluated for spinal and course in 200114 their AA intravenous -Regional workers anesthesia, imbalance, with -Training: though only rural areas Prerequisite -3 of the 12 40% were lacking health nursing or health trained AAs skilled in workers who can assistant degree. surveyed for general deliver Six month training an evaluation anesthesia or anesthesia course replaced had not been anesthesia previous shorter involved in by and ad-hoc training surgery at their intubation52 in anesthesia14 hospital and 10 did not have No evidence -Recognition: No AA-specific found on formal post or job comparative professional description. outcomes of development for surgery. AA. There is an -Physician AAT Advocacy confidence in committee14 the skills of the AA is 70% for cesarean section14 15 Political Economic Context Nepal Political: While initially the Anesthesia Assistant (AA) training was performed on an ad hoc basis, the government institutionalized a 3-month training program for AA in 1996. According to Freedman’s summary, the government regards the policy as a short-term solution until enough physicians are trained in anesthesia14. Professional: The health system is based on a physician-dominated model. A small-scale evaluation in 2004 found that most physicians interviewed were satisfied with the work of the AA, and found their role necessary. Although no information was found on the official positions of physician and specialist organizations on the AA program, it is likely that there was less reaction to the policy due to its intention as a short-term program until more anesthesiologists can be trained. AA is not an official job post; the health workers with this training do not have anesthesia provision as part of their job description, and there is currently no career advancement. Legal/Regulatory: The AAs are permitted to administer anesthesia during surgery when supervised by a physician. AAs are not registered. Gross National Income per capita; purchasing power parity (i) $1,630 (2006) Maternal mortality ratio (MMR) (ii) 830 per 100,000 live births (2005) Percent of births with skilled attendant (ii) 19% (2000-06) Notification of Maternal Deaths (ii) Part (2008) Costed plan for MNH (ii) Yes (2008) Availability of EmOC (ii) 46% (2007) Midwives recognized (ii) Part (2008) Non-physicians authorized in EmOC surgery (iii) Data not available Physician density (iv) 0.21 per 1000 (2004) Midwife density (iv) 0.24 per 1000 (2004) Nurse density (iv) 0.22 per 1000 (2004) Health worked density (combined) (ii) 0.7 per 1000 (2004) Per person health expenditure (international dollars) (i) $71 (2008) Out of pocket health expenditure (ii ) 64.9% (2008) Percent at less than $1 per day (i) 24.1% Percent rural (i) 84.7% (2003-05) Life expectancy at birth (iv) 61 (2004) i. World Bank World Development Report 2008 ii. Millennium Countdown Working Group, 2008 iii. Kowalewski & Jahn, 2001 iv. WHO World Health Report, 2006 16 Table 1: Policy Options for Human Resources for Maternal and Neonatal Health, cont Country and HR Policy Action Other Relevant Regional Process Economic Outcome Underlying Policy Action distribution Evaluation Evaluation Evaluation Problem effects Pakistan Rational -Medical doctors -75% of the -In 2001, only -Worries that -No -Shortage of utilization: are legally LHW service 37,838 of the program evaluation of skilled female Improve skills of permitted to areas are 58,000 LHW will not be LHW health community health perform surgery rural54 posts (and sustainable program with professionals workers and including 100,000 when scaled- MNH improve referral emergency originally up54 outcomes -Cultural chain obstetrics33 planned posts) constraints Pakistan trained the were filled, No cost- -Modern contribute to Lady Health -The national partly due to effectiveness contraceptive delays in care- Worker cadre Maternal and lack of studies found use increased seeking for (started in 1994) to Neonatal Health funding54 significantly females, provide BEmONC Program aims to among areas including for as part of the train 12,000 -However, the served by obstetric National Maternal community program LHW54 emergencies and Child Health midwives, 15,000 gained Program*53, in health care momentum, -The percent -High rates of addition to family providers in and by 2005, of births with home delivery planning and EmONC, and 95,000 LHW skilled without skilled primary health care recruit 324 had been attendant attendant services already midwifery tutors53 recruited53 increased (>89%)38 provided from 18% in -Recruitment 1996/7 to -High maternal -LHW are attached and retention 31% in mortality to a public sector is hampered by 2005/653 health facility; constraints on [association some duties are women not to with LHW performed door to work or travel not tested] door to provide freely9 access to women. - In a cluster LHW are also used RCT, to supervise/link perinatal TBA to health mortality system in was reduced demonstration sites by TBA training -Training: combined Requisite 8 years with safe basic education to birthing kits apply, then a 15 and linkages month training to the health period54 system by the LHW38 -Recognition: Not However, the considered a change in “skilled� health maternal professional; paid mortality an allowance54 was not statistically significant. 17 Political Economic Context Pakistan Political: Unlike Sri Lanka and Malaysia, Pakistan has not prioritized the improvement of women’s rights. The Lady Health Worker program was initiated to overcome the limitations of women’s ability to travel freely and seek care in facilities. Professional: The Lady Health Workers undergo training but are not skilled health workers. Legal/Regulatory: Lady Health Workers are not qualified to provide life-saving skills. Gross National Income per capita; purchasing power parity (i) $2,500 (2006) Maternal mortality ratio (MMR) (ii) 320 per 100,000 live births (2005) Percent of births with skilled attendant (ii) 31% (2000-06) Notification of Maternal Deaths (ii) No (2008) Costed plan for MNH (ii) Yes (2008) Availability of EmOC (ii) no data Midwives recognized (ii) Part (2008) Non-physicians authorized in EmOC surgery (iii) No Physician density (iv) 0.74 per 1000 (2004) Midwife density (iv) data not available Nurse density (iv) 0.46 per 1000 (2004) Health worked density (combined) (ii) 1.2 per 1000 (2004) Per person health expenditure (international dollars) (i) $48 (2008) Out of pocket health expenditure (ii ) 78.8% (2008) Percent at less than $1 per day (i) 17.0% Percent rural (i) 65.5% (2003-05) Life expectancy at birth (iv) 62 (2004) i. World Bank World Development Report 2008 ii. Millennium Countdown Working Group, 2008 iii. Kowalewski & Jahn, 2001 iv. WHO World Health Report, 2006 18 5. Discussion and Conclusion The summary table (Appendix) and policy options table provide an overview of HRH policies in Sub Saharan Africa and South Asia with implications for maternal and neonatal health. To our knowledge, it is the first document to bridge data from the HRH and the maternal and neonatal health literature. A limitation of the work is the lack of corroboration from key informants within country. Policies are often not documented through the grey and published literature, and can be difficult to obtain electronically. Thus, it is probable that promising policies were missed. It is also likely that some policies have evolved since their last documentation. We identified the most recent publications available to reduce the chances of including an outdated policy. Countries are implementing a range of strategies to overcome their human resource constraints. Our review found that the majority of documented HRH policies with direct effects on maternal and neonatal health involve task-shifting, followed by rational production of health workers with midwifery skills. There is less focus on the management and incentives and geographic distribution policies specific to maternal health, probably because such policies are broadly implemented across cadres of health workers rather than being skill specific. Successful management and incentive policies for the general health system should indirectly improve maternal and neonatal health. The policy options table highlighted the limited knowledge we have of the effect of HRH policies on health, economic, and intermediate outcomes. There is promise of the transferability of each of the policies to other contexts, but those with the best outcomes for maternal health are the midwifery supply strategy of Sri Lanka and Botswana and the surgical technician program in Mozambique. The review identified several gaps and opportunities: Gaps Opportunities • Given the burden of maternal and neonatal • Increase the supply of mid-level cadres, who have mortality in rural areas, more effective better retention in rural areas policies are required to improve the • Recruit and train health workers from rural areas geographic imbalances • Legal and regulatory frameworks are not • Change job descriptions to reflect practice and train consistent with health workforce imbalances appropriately and maternal and neonatal health needs in • Register midwives and mid-level cadres to improve many countries. reputation and quality • There was little operations research and high • Share HRH practices for maternal and neonatal quality evaluation to determine the health between countries effectiveness and cost-effectiveness of HRH • Evaluate HRH policies policies in SSA and SA. 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Health Policy and Planning 20 (2): 117-23. 23 APPENDIX: Summary of HRH policies with potential relationship to MNH Relation to Levels of Country Description Selected Sources MNH care Strategy 1: Rational production of health workers These policies and programs relate to the quantity, quality, and mix of those trained. Relevant policies include funding for slots in medical school, nursing school, and other health worker training and the quality and scope of training. Matlab, -Maternity care program Chowdhury, M. E., R. Botlero, Direct effects community Bangladesh increased government M. Koblinsky, S. K. Saha, G. PHC Dieltiens, and C. Ronsmans. trained midwives, 2007. "Determinants of strengthened referral Reduction in Maternal Mortality systems, and increased in Matlab, Bangladesh: a 30- access to EmOC Year Cohort Study." Lancet 370 -Appeared successful, (9595): 1320-1328. though the reason for Graham, W.J., Bell, J.S., and decline was contested Bullough, C.H.W. Can skilled attendance at delivery reduce maternal mortality in developing countries? In Brouwere & Van Lerberghe, eds. 2001. Maine, D., M. Z. Akalin, J. Chakraborty, A. de Francisco, and M. Strong. 1996. "Why Did Maternal Mortality Decline in Matlab?" Stud.Fam.Plann. 27 (4): 179-87. Ronsmans, C., A. M. Vanneste, J. Chakraborty, and J. van Ginneken. 1997. "Decline in Maternal Mortality in Matlab, Bangladesh: a Cautionary Tale." The Lancet 350 (9094): 1810- 1814. Botswana -Increase funding for Egger, D., Lispon, D., and Indirect effects PHC physicians to be trained Adams, O. Achieving the right Secondary balance: The role of policy- (outside of country; no making processes in managing medical school) human resources for health problems. 2000. Issues in -Made continuing Health Services Delivery education a priority Discussion Paper No. 2. -Increase the number of nurse practitioners and pharmacists trained Guinea-Bissau -Reduced the number of Egger, D., Lispon, D., and Indirect effects PHC admissions to medical Adams, O. Achieving the right Secondary balance: The role of policy- school in order to devote making processes in managing more resources to training human resources for health lower level health workers problems. 2000. Issues in Health Services Delivery Discussion Paper No. 2. i APPENDIX: Summary of HRH policies with potential relationship to MNH Relation to Levels of Country Description Selected Sources MNH care India - The Federation of UN Millennium Project Task Direct effects PHC Obstetric and Gynecology Force on Child Health and Secondary Maternal Health. Who's got the Societies of India proposed power? Transforming health an initiative to train systems for women and nonspecialist doctors children. 2005. London, United (medical officers) in Nations Development providing emergency Programme. obstetric care, including cesarean section -The government of India plans to support the initiative [currently is stalled in the courts] Namibia -Increased recruitment and Buchan, J. and Jim McCaffery. Indirect effects PHC rapid deployment of 500 2007. "Health Workforce Secondary Innovations: A Synthesis of clinical and non-clinical Four Promising Practices". health workers to deliver Chapel Hill, NC: The Capacity HIV care, mainly Project. contracted from other countries Nepal - Anesthesia Assistant Freedman, L. 2007. Summary Direct effects PHC (AA) Course Development Review of evidence on Secondary anesthesia provision by mid- in Nepal level providers. Averting Maternal Death and Disability, Columbia University: New York. The Philippines -Trained and placed more Egger, D., Lispon, D., and Direct effects PHC midwives Adams, O. Achieving the right balance: The role of policy- making processes in managing human resources for health problems. 2000. Issues in Health Services Delivery Discussion Paper No. 2. ii APPENDIX: Summary of HRH policies with potential relationship to MNH Relation to Levels of Country Description Selected Sources MNH care Strategy 2: Rational utilization of professionalized health workers Rational utilization of health workers includes the delegation of functions to less skilled health workers, the distribution of health workers within the country, and the method of service delivery. Policies pertaining to distribution of health workers within a country are largely regulatory, since the incentives used through Strategy 4 also have implications for distribution if they are offered differentially. A. Delegation of skills Bangladesh -Physicians may perform Kowalewski M, Jahn A. Health Direct effects PHC surgeries if they obtain Professionals for Maternity Secondary Services: Experiences on additional training covering the population with quality maternity care. In Van Lerberghe W, Brouwere V, eds. Safe Motherhood Strategies: A Review of the Evidence, Antwerp: ITG Press, 2001. Burkina Faso -Training of UN Millennium Project Interim Direct effects PHC paraprofessionals to Report perform C section Ghana -Task shifting by using Buchan, J. and Jim McCaffery. Indirect effects community community health officers 2007. "Health Workforce PHC Innovations: A Synthesis of (CHOs), which are Four Promising Practices". auxiliary nurses with 2 yrs Chapel Hill, NC: The Capacity training. 310 have been Project. deployed. Provide basic healthcare to rural areas through mobile clinics. Ghana -“Life Saving Skills Dovlo, Delanyo. 2004. "Using Direct effects community Training Project� trained Mid-Level Cadres As PHC Substitutes for Internationally midwives in EmOC Mobile Health Professionals in Africa. A Desk Review." Human Resources for Health 2 (1): 7. Ethiopia -Midwives provide all UN Millennium Project Interim Direct effects PHC basic EmOC functions Report Ethiopia -Trained health officers to Tulenko, K. and Farahani, M. Direct effects PHC perform C-sections; have Africa Health Worker Crisis: Secondary Options for Removing had good retention rates Bottlenecks to HIV/AIDS Prevention, Diagnosis, Treatment and Care. The World Bank: Washington DC Dugger, C.W. 2004. Lacking doctors, Africa is training substitutes. New York Times. November 23, 2004. iii APPENDIX: Summary of HRH policies with potential relationship to MNH Relation to Levels of Country Description Selected Sources MNH care India -General practitioners UN Millennium Project Interim Direct effects PHC perform sterilizations and Report induced abortion India -The creation and training UN Millennium Project Interim Direct effects community of the auxialiary nurse Report PHC midwife (ANM) cadre had limited success in attending deliveries due to her short hours “on call� in the village Malawi -Clinical officers Chilopora, G., C. Pereira, F. Direct effects PHC outnumber doctors 3:1 and Kamwendo, A. Chimbiri, E. Secondary Malunga, and S. Bergstrom. are trained to provide 2007. "Postoperative Outcome emergency obstetric care of Caesarean Sections and Other Major Emergency Obstetric -Clinical Officers Surgery by Clinical Officers and administering anesthesia Medical Officers in Malawi." Human Resources for Health 5 had higher mortality rates (1): 17. than trained anesthesiologists, but still Fenton, P. M., C. J. M. Whitty, better outcome than had et al. 2003. "Caesarean section women had to wait longer in Malawi: prospective study of early maternal and perinatal for care mortality." British Medical Journal 327(7415): 587 Dugger, C.W. 2004. Lacking doctors, Africa is training substitutes. New York Times. November 23, 2004. Hongoro, C. and B. McPake. 2004. "How to bridge the gap in human resources for health." The Lancet 364(9443): 1451- 1456. Freedman, L. 2007. Summary Review of evidence on anesthesia provision by mid- level providers. Averting Maternal Death and Disability, Columbia University: New York. iv APPENDIX: Summary of HRH policies with potential relationship to MNH Relation to Levels of Country Description Selected Sources MNH care Mozambique -Surgical technicians and Pereira C, Bugalho A, Direct effects PHC assistant medical officer Bergstrom S, Vaz F, Cotiro M. Secondary 1996. A comparative study of cadres provide skilled care caesarean deliveries by assistant including EmOC medical officers and obstetricians in Mozambique. -Surgical technicians can Br.J Obstet.Gynaeco.l;103:508- perform cesarean section, a 12. hysterectomy, dilation and Kruk, M. E., C. Pereira, F. Vaz, curettage, tubal ligation, S. Bergstrom, and S. Galea. removal of ectopic 2007. "Economic Evaluation of pregnancy, and repair of Surgically Trained Assistant ruptured uterus in rural Medical Officers in Performing Major Obstetric Surgery in areas Mozambique." BJOG. 114 (10): 1253-60. -AMOs are more likely to stay in rural areas than da, Luz, V and S. Bergstrom. doctors 1992. "Mozambique-- Delegation of Responsibility in the Area of Maternal Care." -Other health professionals Int.J Gynaecol.Obstet. 38 Suppl: have positive opinions of S37-S39. AMOs Cumbi, Amelia, Caetano Pereira, Raimundo Malalane, -Cost-effectiveness data Fernando Vaz, Colin McCord, Alberta Bacci, and Staffan Bergstr÷m. 2007. "Major Surgery Delegation to Mid- Level Health Practitioners in Mozambique: Health Professionals' Perceptions." Human Resources for Health 5 (1): 27. Pereira, C., A. Cumbi, R. Malalane, F. Vaz, C. McCord, A. Bacci, and S. Bergstrom. 2007. "Meeting the Need for Emergency Obstetric Care in Mozambique: Work Performance and Histories of Medical Doctors and Assistant Medical Officers Trained for Surgery." BJOG. 114 (12): 1530-1533. Vaz, F., S. Bergstrom, Mda L. Vaz, J. Langa, and A. Bugalho. 1999. "Training Medical Assistants for Surgery." Bulletin of the World Health Organization 77 (8): 688-91. Tulenko, K. and Farahani, M. v Africa Health Worker Crisis: Options for Removing Bottlenecks to HIV/AIDS APPENDIX: Summary of HRH policies with potential relationship to MNH Relation to Levels of Country Description Selected Sources MNH care Nepal - A cadre of medical Kowalewski M, Jahn A. Health Direct effects PHC doctors with two years Professionals for Maternity Secondary Services: Experiences on training for surgery and covering the population with obstetrics work in rural quality maternity care. In Van hospitals and provide Lerberghe W, Brouwere V, eds. emergency obstetric care. Safe Motherhood Strategies: A Review of the Evidence, Antwerp: ITG Press, 2001 Nepal -Midwives provide all UN Millennium Project Interim Direct effects PHC basic EmOC functions Report Pakistan -The license to practice Kowalewski M, Jahn A. Health Direct effects PHC medicine (MBBS) implies Professionals for Maternity Secondary Services: Experiences on that you are able to covering the population with perform surgery including quality maternity care. In Van caesarean section. Lerberghe W, Brouwere V, eds. However in government Safe Motherhood Strategies: A hospitals C-sections are Review of the Evidence, Antwerp: ITG Press, 2001. performed by obstetrics and gynecology The Philippines -Expanded training for Egger, D., Lispon, D., and Direct effects PHC nurse midwives and Adams, O. Achieving the right balance: The role of policy- midlevel providers making processes in managing human resources for health problems. 2000. Issues in Health Services Delivery Discussion Paper No. 2. Tanzania -Trained medical assistants Bewes P. Learning from low Direct effects PHC to perform many physician income countries: what are the Secondary lessons? Trained medical functions, including assistants can successfully do anesthesia delivery work of doctors. BMJ through a partnership with 2004;329:1184. the Kilimanjaro Christian Medical Centre in Moshi Tanzania -Midwives provide all UN Millennium Project Interim Direct effects PHC basic EmOC functions Report Zambia -Changed laws to allow Dovlo, Delanyo. 2004. "Using Direct effects PHC nurses and midwives to Mid-Level Cadres As Secondary Substitutes for Internationally perform post abortion care, Mobile Health Professionals in as well as insertion and Africa. A Desk Review." removals of intrauterine Human Resources for Health 2 devices, and other roles (1): 7. previously limited to physicians vi APPENDIX: Summary of HRH policies with potential relationship to MNH Relation to Levels of Country Description Selected Sources MNH care B. Within-country distribution Indonesia -Increasing continuing Egger, D., Lispon, D., and Indirect effects PHC education requirements for Adams, O. Achieving the right Secondary balance: The role of policy- health workers making processes in managing human resources for health -Modified its mandatory problems. 2000. Issues in service requirement to a Health Services Delivery contract program with Discussion Paper No. 2. doctors and nurse- midwives serving in rural areas for a period of three years. Contracted professionals are paid more than those working in urban areas or as civil servants, although public service remains a prerequisite for obtaining a license to practice. Kenya - 2500 unemployed nurses Kumar P. Providing the Indirect effects PHC are being hired under Providers -- Remedying Africa's Secondary Shortage of Health Care contracts that include a Workers. N Engl J Med requirement to stay in rural 2007;356:2564-7. areas (with international funding) Myanmar -Requires all medical Egger, D., Lispon, D., and Indirect effects PHC school graduates to spend Adams, O. Achieving the right Secondary balance: The role of policy- 3 years working in the making processes in managing public sector, some of the human resources for health time in rural areas problems. 2000. Issues in Health Services Delivery -All applicants to the Discussion Paper No. 2. Doctorate in Medical Science degree program must have at least 2 years of public sector experience The Philippines -“Doctors for the barrios� Egger, D., Lispon, D., and Indirect effects PHC program increases salaries Adams, O. Achieving the right balance: The role of policy- in underserved areas making processes in managing human resources for health problems. 2000. Issues in Health Services Delivery Discussion Paper No. 2. vii APPENDIX: Summary of HRH policies with potential relationship to MNH Relation to Levels of Country Description Selected Sources MNH care South Africa -In the rural Mosvold Kumar P. Providing the Indirect effects PHC District local students Providers -- Remedying Africa's Secondary Shortage of Health Care receive scholarships for Workers. N Engl J Med health care training on the 2007;356:2564-7. condition that they agree to return to the district to practice: PHR report that trainees from rural areas were three to eight times as likely as those from urban areas to practice in rural regions after graduation. C. Improving balance between the public and private sectors Gujarat State, -State government Mavalankar, D. V., A. Singh, R. Direct effects PHC India contracts with private ob- Bhat, A. Desai, and S. R. Patel. Secondary 2008. "Indian Public-Private gyns to provide obstetric Partnership for Skilled Birth- care to poor women Attendance." The Lancet 371 (9613): 631-32. -As of 2007, 830 ob-gyns were enrolled and 131,000 deliveries were attended (6% cesarean rate) viii APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care Strategy 3: Rational utilization of community health workers While recognizing the goal of having a skilled attendant at every birth, there is a need to train community health workers, traditional birth attendants, and other community members to provide support maternal and neonatal care. Policies that create, train, and collaborate with unskilled health workers in the community are often undertaken in settings where the number of skilled attendants is insufficient and the majority of births occur in the home. These include the creation of new cadres of community health workers, on a paid or volunteer basis; the training of community health workers in life saving skills such as neonatal resuscitation, provision of oral misoprostol to prevent postpartum hemorrhage, and clean delivery techniques to reduce sepsis; as well as the closer integration between the traditional attendants and government health workers. Strategies to strengthen referral networks between community level health workers such as traditional birth attendants and the primary health facilities improve the rational utilization of existing services. These policies aim to reduce the delay in the decision to seek care for obstetric complications and reduce the delay in reaching an appropriate facility. Angola -Community-based health Egger, D., Lispon, D., and Indirect effects community promoters are used to deliver Adams, O. Achieving the right balance: The role of policy- primary care making processes in managing human resources for health problems. 2000. Issues in Health Services Delivery Discussion Paper No. 2. Bangladesh -BRAC has trained 30,000 UN Millennium Project Task Direct effects community community health workers, Force on Child Health and Maternal Health. Who's got the unpaid female volunteers, power? Transforming health who provide FP services systems for women and along with many basic health children. 2005. London, United care services Nations Development Programme. Bangladesh -TBA training alone did not White Ribbon Alliance for Safe Direct effects community reduce MMR Motherhood/India. 2002. Saving mothers’ lives: what works. White Ribbon Alliance for Safe Motherhood: New Delhi and Washington DC Bangladesh -TBA training in tetanus Walraven G., Weeks A. 1999. Direct effects community toxoid reduced neonatal The Role of (traditional) Birth Attendants with Midwifery mortality Skills in the reduction of maternal mortality. Tropical Medicine and International Health 4. White Ribbon Alliance for Safe Motherhood/India. 2002. Saving mothers’ lives: what works. White Ribbon Alliance for Safe Motherhood: New Delhi and Washington DC ix APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care Bangladesh -Government intends to train UN Mill Project Interim Report Direct effects community family welfare visitors as Mridha, M. M. and M. M. Khan. nurse midwives 2000. "Appraisal of the Institutional Training Arrangement for Community Health Workers in Bangladesh." Human Resources for Health Development Journal 2 (2). Burkina Faso -TBA training along with White Ribbon Alliance for Safe Direct effects community emergency transport and Motherhood/India. 2002. Secondary Saving mothers’ lives: what referral has reduced perinatal works. White Ribbon Alliance mortality for Safe Motherhood: New Delhi and Washington DC Ghana -TBA training has not White Ribbon Alliance for Safe Direct effects community increased referrals and some Motherhood/India. 2002. Saving mothers’ lives: what TBAs have attempted to works. White Ribbon Alliance provide complex for Safe Motherhood: New interventions (such as Delhi and Washington DC administering oxytocics) with negative effects India -Training TBAs through the Bang AT, Bang RA, Baitule SB, Direct effects community SEARCH Project is Reddy MH, Deshmukh MD. 1999. Effect of home-based associated with reduced neonatal care and management neonatal mortality of sepsis on neonatal mortality: field trial in rural India. Lancet;354:1955-61. Bang AT, Reddy HM, Deshmukh MD, Baitule SB, Bang RA. 2005. Neonatal and infant mortality in the ten years (1993 to 2003) of the Gadchiroli field trial: effect of home-based neonatal care. J Perinatol;25 Suppl 1:S92-107. Bang AT, Bang RA, Baitule SB, Reddy HM, Deshmukh MD. 2005. Management of birth asphyxia in home deliveries in rural Gadchiroli: the effect of two types of birth attendants and of resuscitating with mouth-to- mouth, tube-mask or bag-mask. J Perinatol.;25 Suppl 1:S82- S91 White Ribbon Alliance for Safe Motherhood/India. 2002. Saving mothers’ lives: what x APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care works. White Ribbon Alliance for Safe Motherhood: New Delhi and Washington DC UN Millennium Project Interim Report Indonesia -Partnership between TBAs, www.who.int/making_pregnanc Direct effects community midwives, and women to y_safer.com PHC establish referrals Cholil, A., M.B. Iskander, and -Clear delineation of skills to R.Sciortino. (1998) The Life be performed by TBA (clean Saver: The Mother Friendly cord care, post partum Movement in Indonesia. Jakarta: washing and massage) and The State Ministry for the Role of Women, Republic of the midwife (intrapartum Indonesia and The Ford care) Foundation. White Ribbon Alliance for Safe Motherhood/India. 2002. Saving mothers’ lives: what works. White Ribbon Alliance for Safe Motherhood: New Delhi and Washington DC Indonesia The village midwives cadre UN Millennium Project Interim Direct effects community was created to expand access Report to maternal care Indonesia -The USAID/John Snow UN Millennium Project Interim Direct effects community International Mothercare Report Project “attempted to Ronsmans C,.Achadi E. upgrade village midwives’ Evaluation of a comprehensive skills and capacities to home-based midwifery program include a fully integrated in South Kalimantan, Indonesia. reproductive health package Tropical Medicine and International Health (including antenatal care, 2001;6:799-810. anemia control, delivery care, postpartum visits, life Koblinsky, M. 2003. Reducing saving skills and neonatal maternal mortality: learning resuscitation). However, from Bolivia, China, Egypt, Honduras, Indonesia, Jamaica progress toward reducing and Zimbabwe. Washington maternal mortality was D.C.: The World Bank. uncertain given inadequate pre-service training, low acceptance of the midwives by the community (despite efforts in the program to work with the TBAs) and a poorly functioning referral system.� xi APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care Malawi -Health Surveillance Indirect effects community Assistants (HSA) are trained to be involved in a wide range of health issues Nepal -Participatory action- Manandhar DS, Osrin D, Direct effects community learning through women’s Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM groups decreased neonatal et al. Effect of a participatory mortality and maternal intervention with women's mortality in a 12 matched- groups on birth outcomes in pair community RCT Nepal: cluster-randomised controlled trial. Lancet 2004;364:970-9. Nepal -Female community health Partnership for MNC Lives Direct effects community volunteers are an unpaid Newsletter cadre involved in maternal and neonatal health Nepal -National TBA training White Ribbon Alliance for Safe Direct effects community program has improved Motherhood/India. 2002. PHC Saving mothers’ lives: what maternal care and reduced works. White Ribbon Alliance neonatal mortality for Safe Motherhood: New -Auxiliary Health Nurses Delhi and Washington DC and Public Health Nurses conducted the trainings Nigeria -TBA training along with White Ribbon Alliance for Safe Direct effects community emergency transport and Motherhood/India. 2002. Saving mothers’ lives: what referral has reduced perinatal works. White Ribbon Alliance mortality for Safe Motherhood: New Delhi and Washington DC Pakistan -Lady health workers have Mumtaz Z, Salway S, Waseem Direct effects community community-based role in M, Umer N. Gender-based barriers to primary health care maternal and child health provision in Pakistan: the and provision of family experience of female providers. planning Health Policy Plan. 2003;18:261-9. -LHW must have 10-12 Jokhio AH, Winter HR, Cheng years of schooling and be KK. An intervention involving local residents traditional birth attendants and perinatal and maternal mortality -Working together with in Pakistan. N.Engl.J Med TBAs to promote good 2005;352:2091-9. obstetric practices, lady health workers reduced neonatal mortality rates Pakistan -Village-based Family Mumtaz Z, Salway S, Waseem Direct effects community Planning Worker (VBFPW) M, Umer N. Gender-based barriers to primary health care cadre are community level xii APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care workers who focus on provision in Pakistan: the provision of information and experience of female providers. Health Policy Plan. methods of family planning 2003;18:261-9. -VBFPW has recently been merged with the Lady Health Workers program Pakistan -Lady Health Visitor is on Mumtaz Z, Salway S, Waseem Direct effects PHC staff at a Basic Health Unit M, Umer N. Gender-based community barriers to primary health care and also makes home visits; provision in Pakistan: the has 10 years of schooling experience of female providers. and 3 years of training Health Policy Plan. 2003;18:261-9. Uganda -RESCUER program to White Ribbon Alliance for Safe Direct effects community promote access to care Motherhood/India. 2002. PHC Saving mothers’ lives: what Secondary through transportation works. White Ribbon Alliance services, referral networks, for Safe Motherhood: New recruiting health workers and Delhi and Washington DC drivers, and increasing communication with skilled care personnel en route to EmOC facility Multi-country -TBA training was found to White Ribbon Alliance for Safe Direct effects community study increase knowledge and was Motherhood/India. 2002. Saving mothers’ lives: what associated with a small but works. White Ribbon Alliance statistically significant for Safe Motherhood: New decline in perinatal mortality Delhi and Washington DC and in neonatal mortality due to birth asphyxia Strategy 4: Compensation and Management Egger et al include “management training, incentives, performance monitoring, and public regulation or contracts with the public sector� under this category. These policies seek to increase productivity and improve job satisfaction. The long term goals are to attract health workers and retain them, reducing the push factors into the private sector and to emigration. These may be used across the health system or selectively to increase the workforce in rural and other underserved areas. Many have focused on physicians but others have included nurses, managers, and other cadres. Botswana -Created a nurse and Egger, D., Lispon, D., and Direct effects PHC midwife management Adams, O. Achieving the right Secondary balance: The role of policy- information system (MIS) to making processes in managing improve allocation and human resources for health projected needs problems. 2000. Issues in Health Services Delivery Discussion Paper No. 2. China -Performance based pay for Liu X,.Mills A. The effect of No effects Secondary hospital doctors have performance-related pay of hospital doctors on hospital increased unnecessary xiii APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care admissions and procedures behaviour: a case study from Shandong, China. Human Resources for Health 2005;3:11. Ghana -Rural incentive programs Tulenko, K. and Farahani, M. Indirect effects PHC for providers have had mixed Africa Health Worker Crisis: Secondary Options for Removing effects Bottlenecks to HIV/AIDS Prevention, Diagnosis, - An "additional duty hours Treatment and Care. The World allowance," implemented in Bank: Washington DC 1998 to compensate doctors Kumar P. Providing the for overtime work, initially Providers -- Remedying Africa's doubled salaries in several Shortage of Health Care geographic areas. But once Workers. N Engl J Med all physicians began to 2007;356:2564-7. expect the additional allowance, the program rapidly became too costly to sustain and was restructured. It also caused resentment among nurses, who received lower allowances than doctors and were therefore increasingly inspired to emigrate. Guinea- -Policy made hospitals more Egger, D., Lispon, D., and Indirect effects PHC Bissau autonomous and allowed Adams, O. Achieving the right Secondary balance: The role of policy- them to make contracts with making processes in managing the private sector for human resources for health nonmedical support services. problems. 2000. Issues in Health Services Delivery -Reformed salary grades and Discussion Paper No. 2. improved living conditions for health workers Indonesia -World Bank-funded Egger, D., Lispon, D., and Indirect effects PHC program of a reward and Adams, O. Achieving the right Secondary balance: The role of policy- incentive system for health making processes in managing workers human resources for health problems. 2000. Issues in Health Services Delivery Discussion Paper No. 2. Malawi -Efforts to retain health Tulenko, K. and Farahani, M. Indirect effects PHC workers with higher salaries Africa Health Worker Crisis: Secondary Options for Removing (supported by DFID) Bottlenecks to HIV/AIDS Prevention, Diagnosis, -Increased salaries of the Treatment and Care. The World nurse tutors/instructors and Bank: Washington DC xiv APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care provide free housing (supported by Interchurch Buchan, J. and Jim McCaffery. 2007. "Health Workforce Organization for Innovations: A Synthesis of Development Cooperation Four Promising Practices". and later GTZ) Chapel Hill, NC: The Capacity Project. Nigeria -After improved supplies and Kumar P. Providing the Indirect effects PHC conditions of health centers, Providers -- Remedying Africa's Shortage of Health Care retention of nurses in the Workers. N Engl J Med rural Ondo State increased 2007;356:2564-7. from 28% to 66% over a 3- year period (though other infrastructure projects, such as improvement of roads may have contributed to this increase) The -Increased pay for public Egger, D., Lispon, D., and Indirect effects PHC Philippines sector health workers and Adams, O. Achieving the right Secondary balance: The role of policy- community barangay health making processes in managing workers human resources for health problems. 2000. Issues in Health Services Delivery Discussion Paper No. 2. Rwanda -Demonstration projects on Tulenko, K. and Farahani, M. Indirect effects PHC block granting wages to Africa Health Worker Crisis: Secondary Options for Removing enable the use of Bottlenecks to HIV/AIDS performance based pay and Prevention, Diagnosis, to circumvent wage bill Treatment and Care. The World ceilings Bank: Washington DC Uganda -Incentives packages that Kumar P. Providing the Indirect effects PHC include lunch Providers -- Remedying Africa's Secondary Shortage of Health Care Workers. N Engl J Med -Decentralization of the 2007;356:2564-7. health system has increased nepotism but improved Kanyesigye, E. K. and G. M. communication between Ssendyona. 2004. "Payment of Lunch Allowance: A Case Study managers and health workers of the Uganda Health Service". JLI Working Paper 4-2. The Joint Learning Initiative. Ssengooba, Freddie, Syed Rahman, Charles Hongoro, Elizeus Rutebemberwa, Ahmed Mustafa, Tara Kielmann, and Barbara McPake. 2007. "Health Sector Reforms and Human Resources for Health in Uganda xv APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care and Bangladesh: Mechanisms of Effect." Human Resources for Health 5 (1): 3. Zambia -Doctor’s retention program Tulenko, K. and Farahani, M. Indirect effects PHC Africa Health Worker Crisis: Secondary Options for Removing -Incentive program for Bottlenecks to HIV/AIDS physicians who serve for 3 Prevention, Diagnosis, years in a rural area. These Treatment and Care. The World benefits include a hardship Bank: Washington DC allowance, an education http://zambia.usembassy.gov/za allowance for children, mbia/pr051105.html, accessed housing, and some funding 09/05/06 for postgraduate training. Kumar P. Providing the Providers -- Remedying Africa's Shortage of Health Care Workers. N Engl J Med 2007;356:2564-7. Strategies from Historic Success Stories in Reducing Maternal Mortality Botswana -IEC to increase community Family Care International. Direct effects PHC awareness of maternal 2002. Skilled care during Secondary childbirth: Country Profiles. mortality FCI: New York -Political will to reduce maternal mortality -Increase in the number of nurses and midwives trained -Supply of health workers increased in rural areas China -Minimally trained TBAs White Ribbon Alliance for Safe Direct effects community with strong referral networks Motherhood/India. 2002. PHC Saving mothers’ lives: what and EmOC reduced MMR works. White Ribbon Alliance between 1950 and 1980 for Safe Motherhood: New Delhi and Washington DC Malaysia -Training of midwives Pathmanathan, I. and Direct effects community -Good pay and respect for Liljestrand, J. eds. 2003. PHC Investing effectively in maternal midwives health in Malaysia and Sri -Investment in primary Lanka. The World Bank: health system Washington, DC -Reached multiple geographic locations and UN Millennium Project Background Paper of the Task ethnic groups; having Force on Child Health and midwives available at the Maternal Health community level -Initial program involved White Ribbon Alliance for Safe TBAs with midwives but Motherhood/India. 2002. Saving mothers’ lives: what utilization has shifted works. White Ribbon Alliance towards midwives for Safe Motherhood: New xvi APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care -Regulations on tasks to be Delhi and Washington DC performed by cadres was Family Care International. flexible to overcome gaps in 2002. Skilled care during access to underserved areas childbirth: Country Profiles. -Improved the monitoring of FCI: New York outcomes and maternal death audit to improve quality Sri Lanka -Training of midwives Pathmanathan, I. and Direct effects community -Good pay and respect for Liljestrand, J. eds. 2003. PHC Investing effectively in maternal midwives health in Malaysia and Sri -Investment in health system, Lanka. The World Bank: including EmOC Washington, DC -Reached multiple geographic locations and Family Care International. 2002. Skilled care during ethnic groups childbirth: Country Profiles. -Regulations on tasks to be FCI: New York performed by cadres was flexible to overcome gaps in Freedman et al. 2003 access to underserved areas Millennium Project Background Paper of the Task Force on -Increased access to family Child Health and Maternal planning Health -Investment in education and female literacy White Ribbon Alliance for Safe -Government subsidized Motherhood/India. 2002. Saving mothers’ lives: what transport fees between PHC works. White Ribbon Alliance and referral sites for Safe Motherhood: New Delhi and Washington DC Tunisia -Increased the number of Family Care International. Direct effects community trained and legally 2002. Skilled care during PHC childbirth: Country Profiles. recognized midwives FCI: New York -Midwives are primarily responsible for providing family planning, as per national policy Unsuccessful attempts at HRH reform Ghana -Nurses professional UN Millennium Project Task Indirect effects PHC Kenya association banned attempts Force on Child Health and Maternal Health. Who's got the Malawi to create “enrolled nurses,� power? Transforming health Zambia who have less training than systems for women and registered nurses children. 2005. London, United Nations Development Programme. Dovlo D. Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review. Human Resources for xvii APPENDIX: Summary of HRH policies with potential relationship to MNH Relation Levels of Country Description Selected Sources to MNH care Health 2004;2:7. Zimbabwe -Physician-dominated UN Millennium Project Task Indirect effects PHC organization blocked nurses’ Force on Child Health and Maternal Health. Who's got the right to prescribe drugs in power? Transforming health the private sector; it is systems for women and allowed in the public sector children. 2005. London, United Nations Development Programme. xviii