REGIONAL COMMITTEE Sixty-first Session SEARO, New Delhi 8–11 September 2008
Provisional Agenda item 12 SEA/RC61/10 18 July 2008
MANAGING HUMAN RESOURCES FOR ACCELERATING REDUCTION OF MATERNAL AND NEONATAL MORTALITIES The attached paper describes how the community-based health providers for maternal and newborn health (MNH) in some countries of the Region are often insufficient in number, as well as in their midwifery skills. As a result, there is limited access to skilled care at birth, especially for marginalized communities. Also, there are a limited number of specialists usually concentrated in urban areas. The lack of and inequity in access to skilled care at birth, emergency obstetric care and management of problems of the newborns hamper the efforts to reduce maternal and neonatal mortality as targeted in the Millennium Development Goals 4 and 5. To address these challenges, it is proposed that all Member countries in the South-East Asia (SEA) Region strengthen their national database on human resources for MNH; develop a long-term national plan to address the gaps of human resources for MNH by category and ensure adequate resources and effective implementation; strengthen human resource management for MNH services; and work with partners, nongovernmental organizations (NGOs) and stakeholders in developing a clear policy and plan on skilled birth attendants (SBAs). Besides those actions at the policy level, other actions are also needed at the entry level for preparing the workforce; at the workforce level for enhancing performance; and at the exit level for managing attrition. WHO should advocate for increasing the investment in human resources for MNH and to work together with Member countries in addressing the key challenges. This paper was discussed at the Meeting of the Advisory Committee (ACM) held in SEARO, New Delhi, from 30 June to 3 July 2008. The ACM made the following recommendations:
Action by Member States (1) Identify innovative strategies and actions to address the issues and challenges of human resources for MNH at policy, entry, workforce and exit levels, taking into account the sociocultural context in countries; Build common understanding on the training of skilled birth attendants (SBA) and utilize evidence-based information on the impact of socio-cultural factors on MNH; Arrange training for the existing health workers to meet the needs of birth attendants of the Member countries as interim measures, as required;
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Provide more attention to key areas of MNH, i.e. newborn health and its dependence on maternal health, maternal nutrition and breastfeeding, postpartum haemorrhage, etc., and ensure that such aspects are included in training of SBAs for MNH; and Utilize community-based health workers and volunteers in providing psychosocial support to mothers and families along with other public health interventions.
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Action by WHO/SEARO (1) (2) Provide country-specific guidance in managing health workforce in MNH and advocate for relevant policy issues; Collaborate and coordinate with other UN agencies and development partners in addressing the issues and challenges of human resources and other MNH programme issues to foster the implementation of actions in an integrated manner; and Promote the use and implementation of evidence-based policies, standards and tools for improving human resources for MNH.
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The paper is now submitted to the Sixty-first Session of the Regional Committee for its consideration.
Contents List of acronyms...........................................................................................................................1 Executive summary......................................................................................................................1 Background .................................................................................................................................2 Situation analysis .........................................................................................................................3 The maternal and newborn health situation in the SEA Region, 2000–2005 ......................................3 The situation of various categories of human resources in MNH service ............................................5 Key initiatives in countries for improving human resources for MNH.................................................8 WHO resolutions, strategies and tools ..............................................................................................9
Key issues and challenges in human resources for MNH ..............................................................9 Policy level ....................................................................................................................................10 Entry: Preparing the workforce .......................................................................................................10 Workforce: Enhancing worker performance ...................................................................................10 Exit: Managing attrition ..................................................................................................................11
The way forward for Member States and the role of WHO ........................................................11 The way forward for Member States ...............................................................................................11 The roles of WHO .........................................................................................................................13
Suggested further reading ..........................................................................................................13 Annexes 1. 2. Categories and number of human resources for MNH.......................................................15 Educational background, programme of study and duration of programme of selected human resources for MNH ..................................................................................17
List of acronyms ANM FWA HA MDG MMR MNH NMR SBA TBA auxiliary nurse midwives female welfare assistant health assistant Millennium Development Goal maternal mortality ratio maternal and newborn health neonatal mortality rate skilled birth attendants traditional birth attendants
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Executive summary 1. Experiences from countries successful in curbing maternal and neonatal deaths show that one of the key factors for the reduction of maternal and newborn mortality is the availability of skilled birth attendants (SBAs) at the community level. This is combined with a referral back-up that provides obstetric care for mothers and special care for newborns with problems in a functioning health system. It also shows that these countries have relatively adequate numbers and better management of human resources for maternal and newborn health. The fifty-eight Session of the Regional Committee in 2005 endorsed a resolution on Skilled care at every birth that urges Member States, among others, “to review the gaps in human resources for skilled care at birth and, as appropriate, to develop or modify human resource policies for skilled care at birth, which includes planning, production, placement, retention and career development”. 2. The WHO South-East Asia Region accounts for nearly one-fourth of the world’s population while contributing to approximately a third of the global maternal and neonatal deaths. In the estimated 37 million childbirths that occur here annually, the total number of maternal deaths in 2005 was estimated at 170 000 and neonatal deaths at 1.3 million. In addition, over one million stillbirths occur in the Region. India, Bangladesh, Indonesia, Nepal and Myanmar contribute to 98% of all maternal and neonatal deaths in the Region. Although most Member countries have made palpable progress on increasing the proportion of deliveries assisted by SBAs, all countries need to reach universal access to skilled care at birth in order to achieve Millennium Development Goal (MDG) 5. 3. Human resources for maternal and newborn health (MNH) include formal health-care providers or health professionals and informal health-care providers. The formal providers include community-based health providers for MNH, community-based midwife, professional nurse/nurse-midwife/midwife, medical doctors, specialists in obstetrics and in neonatology, and other supporting providers. In some countries of the Region, the community-based health providers for MNH are often insufficient in numbers and in their midwifery skills. This creates limited access to skilled care at birth, especially to the marginalized communities. In many countries the number of specialists is very limited and they are usually concentrated in urban areas. This has resulted in inequities in accessing emergency obstetric and special newborn care for the rural community when it is needed. 4. The key issues and challenges in human resources for MNH include those at policy, entry, workforce and exit levels. At the policy level, the lack of a clear policy and plan on human resources for MNH is a challenge. Inadequate number of community-based SBAs and specialists is also a major challenge that needs consideration. At the entry level, in preparing the workforce issues of pre-service training, recruitment and distribution of human resources for MNH, especially in remote areas, remain a challenge. The challenges to enhancing the worker performance are: poor working environment, excessive workload of MNH providers and inadequate supervision and monitoring system. At the exit level, the challenges in managing attrition include lack of data on national turnover rate of each category of workforce and lack of retirement and succession planning.
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5. The proposed way forward for Member States at the policy level includes: Strengthening of a national database on human resources for MNH, developing a long-term national plan to address the gaps for each category and ensuring adequate resources and effective implementation; strengthening human resource management for MNH service; working with partners, NGOs and stakeholders in the development of a clear policy and plan on SBAs. At the entry level the way forward is building strong institutions for education, assuring educational quality and revitalizing recruitment capabilities. At the workforce level what is required is bolstering a supervision system, strengthening critical support systems, ensuring lifelong learning and improving collaboration between MNH health providers at the community level and informal heath providers, including community health volunteers and traditional birth attendants. At the exit level managing migration of health workers and enhancing retirement and succession planning are key aspects. 6. The roles of WHO are to advocate for increasing investment in human resources for MNH and working together with Member countries at the policy level to assist them in strengthening human resource management for MNH service, promote the use and implementation of evidence-based policies, standards and tools for improving human resources for MNH, facilitate collaboration among stakeholders and catalyze knowledge and learning exchange, and support studies/research in the area of human resources for MNH.
Background 7. The WHO South-East Asia (SEA) Region in 2005 accounted for approximately 170 000 maternal and 1.3 million neonatal deaths, which are 31.7% and 35% of the global figures 2 1
respectively. In addition, over one million stillbirths occur in the Region every year. Experiences from countries successful in curbing maternal and neonatal deaths show that one of the key factors that contributed to the reduction of such mortalities is the availability of skilled birth attendants (SBAs) at the community level. This is combined with a referral back-up that provides obstetric care for mothers and special care for newborns with problems, in a functioning health system. 8. It also shows that all countries with a low maternal mortality ratio (MMR) and neonatal mortality rate (NMR) have relatively adequate numbers and better management of human resources for maternal and newborn health (MNH). The governments of these countries have also made efforts to ensure that MNH services can be easily accessed by all communities. The World Health Report 2006 on the subject of “Working together for health” dwelled on the importance of developing capable and motivated health workers who have adequate support systems towards achieving national and global health goals. At the heart of every health system lies the human resources that are central to advancing health. 9. As indicated in the technical discussion on “Skilled Care at Every Birth” at the 42nd Consultative Committee for Programme Development and Management (CCPDM) Meeting in 2005, countries in the SEA Region are at different stages of achieving universal access to skilled 1 2
Maternal Mortality in 2005. Estimates developed by WHO, UNICEF, UNFPA and the World Bank, 2007. Neonatal and Perinatal Mortality: Country, Regional and Global Estimates 2004., WHO, 2007.
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care at birth. For countries with a very low proportion of deliveries assisted by skilled attendants, the major problem is lack of an adequate number of SBAs at the community level. Even when the existing health providers are given the responsibility to provide MNH care, they often do not have the required skills, essential equipment/support and back-up referral services. 10. In tackling the problems of human resources for health, the World Health Report 2006 set the goal to get the right workers with the right skills in the right place doing the right things. In achieving this it is necessary to retain the agility to respond to crises, meet current gaps and anticipate the future. The report lays out a “working lifespan” approach, which covers issues of entry, enhancing performance and managing attrition. This can also be applied for improving the management of human resources for MNH in the effort to accelerate the reduction of maternal and neonatal mortalities. 11. This paper aims to raise awareness of SEA Member countries on the issues facing human resources for MNH and to propose the way forward in order to accelerate reduction of maternal and neonatal mortalities to achieve Millennium Development Goal (MDG) 5 and contributing to the achievement of MDG 4 (in reducing neonatal mortality by 50%). It provides information on the situation of maternal and neonatal mortalities in the Region, analysis of the situation and gaps on human resources for MNH and recommendations on the way forward for addressing the issues of human resources for MNH.
Situation analysis The maternal and newborn health situation in the SEA Region, 2000–2005 12. The WHO South-East Asia Region, with its 11 Member countries, accounts for nearly onefourth of the world’s population. Most countries of the Region have very young average populations, with nearly 50% being in the reproductive age-group. An estimated 37 million childbirths take place annually. The Region carries a heavy burden of the global maternal and neonatal mortality. WHO/UNICEF/UNFPA/World Bank estimates for 2000 and 2005 place the total number of maternal deaths at 173 000 and 170 000 (31.7% of the global total) and of neonatal deaths at 1.4 million and 1.3 million (35% of the global total) respectively (Table 1). In addition, over one million stillbirths occur in the Region every year. These deaths are not distributed equally across the Region and there are vast in-country as well as inter-country variations of the degree of inequity in access to skilled care at birth. Table 1. Maternal and neonatal deaths in SEA Region in 2005 Countries Bangladesh Bhutan DPR Korea India No. of maternal deaths 21 000 280 1300 117 000 No. of neonatal deaths 136 000 2000 8000 1 004 000
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Countries Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Total
No. of maternal deaths 19 000 12 3700 6500 190 1100 190 170 272
No. of neonatal deaths 75,000 1000 48 000 25 000 3000 10 000 1000 1 313 000
Source: WHO/UNICEF/UNFPA/World Bank estimates
13. India, Bangladesh, Indonesia, Nepal and Myanmar contribute to 98% of all maternal and neonatal deaths in the SEA Region. Recently, in monitoring the coverage of priority interventions to achieve the MDGs for reduction of maternal and child mortality, the Countdown to 2015 for Maternal, Newborn and Child Survival Initiative reported on 68 countries which together account for 97% of the global maternal, newborn and child deaths. Nepal and Bangladesh are identified as having a very high MMR, while India, Indonesia, Myanmar and DPR Korea are categorized as having a high MMR . Achieving MDG 5 is indeed a great challenge for these countries. 14. More than 60% of births in many countries of the Region occur at home where there are no or few skilled birth attendants . There are, however, wide differentials within countries, both in terms of rural-urban ratios, as well as by income groups or education standards even in countries with a high coverage of skilled care at birth. One of the major differences between countries with high levels of MMR and NMR and those with low levels is that in most low-MMR and low-NMR countries people have high access to skilled care at birth. Most of the countries are making progress on increasing the proportion of deliveries assisted by SBAs, with only three countries, namely Bangladesh, Nepal and Timor-Leste, having the figures of less than 50% (Fig. 1). However, to achieve MDG 5 it is necessary that all countries reach universal access to skilled care at birth or a proportion of at least 80%. DPR Korea, Sri Lanka and Thailand have achieved that level. 4 3
The WHO/UNFPA/UNICEF/World Bank estimates for MMR are being used, which might be different from country figures because of different methods of measurement and difficulties in measuring MMR, as well as the wide range of uncertainty of MMR as an indicator (denominator: per 100,000 live births). 4
3
Skilled birth attendants (SBAs) or skilled attendants are health care providers (particularly those who work at primary care level) with competencies in core midwifery skills. Traditional birth attendants (TBAs), although trained, are not included in SBA category.
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Figure 1: Trend of proportion of births attended by skilled health personnel, 1990–2005 100 90 80 72 70 60 *52 50 42 40 30 20 12 13 15 10 0 Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste
97 97 97 87 98
98 99 91 1990
87
2000 2005
67
70
68 57
54
51 41 32 24 18.7 11 7
34 24
5
SEA Region countries Source: 11 health questions about the 11 SEAR countries, WHO, SEARO, 2007 *Annual Health Bulletin 2007
The situation of various categories of human resources in MNH service 15. There are a number of categories of human resources for MNH with different educational backgrounds working in the countries of the Region (details in Annexes 1 and 2). The roles and functions of each category are varied according to educational background, training experiences and country context.
Formal health-care providers/health professionals 16. This group of human resources for MNH services includes those who are formally trained at different levels of MNH care. (1) Community-based health-providers for MNH. This workforce usually has 8–10 years of basic education and 1–1.5 years of training in primary health care that includes limited expertise on midwifery. This category includes all multipurpose workers and maternal child health workers in Myanmar; auxiliary nurse midwives (ANM) in Bhutan, India and Nepal; health assistants (HA) in Bangladesh and Bhutan; and female welfare assistants (FWA) in Bangladesh. They are expected to provide health promotion and very basic care to pregnant women, mothers and babies. They, however, often do not have the skills to assist childbirth. Many countries in the Region make the effort to upgrade this workforce through midwifery training to enable them to provide child birth care.
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Community-based midwife. This workforce graduated from nursing school (nine years of basic education and three years of nursing education) and trained in midwifery for one year. This type of workforce was produced in Indonesia in large numbers. They perform antenatal, childbirth, post-partum and newborn care in normal conditions and first aid for obstetric complications before referral. They work at the village level and are the backbone of MNH care at the community level. Professional nurse, nurse-midwife and midwife (holding a bachelor’s degree). This workforce has 12 years of basic education and 3–4 years of nursing, nursing and midwifery or midwifery education. They are expected to perform antenatal care, childbirth, postpartum and newborn care and some life-saving interventions when there is no doctor/specialist available. Where referral services are easy to access, women or babies with complications/problems are referred for proper diagnosis and treatment. They usually work in primary health-care centres as well as in hospitals. India has a plan to create posts for nurses to be available on a 24 hour basis the community health centre and primary health-care units. Medical doctors. They have 12 years of basic education and five to seven years of education in medicine, which includes some training in obstetrics and paediatrics. Not all general practitioners practice midwifery/obstetric care after their graduation. However, when there is no specialist, they can be trained to perform key functions of a specialist in obstetrics and paediatrics. Medical doctors usually work in health facilities at the primary-care level or in hospitals. Specialists in obstetrics and in paediatrics/neonatology. This workforce forms the highest level of the health professional for MNH care. The specialists are educated on the subject of specialization for three to four years directly after graduation from medical school or after some years of practising medicine. Another specialist required in assisting surgery in obstetrics (such as Caesarian section) in the second and third referral hospital is the anaesthetist. As this specialization is not yet included in the list of specialists for first referral hospitals, the role is performed usually by a nurse trained in anaesthesia or a technician in this area (which is also the case for other support services such as laboratory and radiology). In many countries the number of these specialists is very limited and they are usually concentrated in urban areas. This has resulted in inequities in accessing emergency obstetric care for the rural community. Specialists mainly work at universities and hospitals.
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17. A skilled birth attendant (SBA) by definition covers all categories of human resources for MNH as above, except Category 1. However, in reality SBAs are often referred to those working at the community or primary-care level, which include Category 2 and 3 above, as well as Category 1 when their skills are upgraded to a level closer to Category 2. Category 4 and 5 are health professionals providing mostly referral back-up care, especially those in Category 5. Universal access to skilled care at birth has an enormous potential for reducing maternal deaths and morbidity, stillbirths and early neonatal deaths. 18. For practical reasons, the ratio of SBAs at the community level is estimated at one for every 5000 inhabitants who account for approximately 150 births per year. It is also expected for every 500 000 population to have an obstetrician, or a medical doctor trained adequately in
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obstetrics, to perform comprehensive emergency obstetric care in a referral hospital. Approximately 1000–1500 obstetric complications would occur for this population, necessitating 450–600 Caesarian sections per year. These estimates can be used or adapted to country situations for purposes of planning at the national and sub national level.
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Informal health-care providers 19. This category includes those who provide promotive service and traditional care for mothers and children in the community and is not an official part of health services delivery. They work in the community and provide home-based care services. They do not go through formal training and participate in the workforce as volunteers or driven by their interest. Therefore, this category may include both those who are illiterate and those having higher pursued education. (1) Community health volunteers (community/village health worker or health cadre). They assist health-care providers in reporting pregnant women and take them for antenatal care, recording births and deaths, weighing under-five children and providing basic health information. They are usually live in and a part of the same community of the client and, therefore, are familiar with the women concerned and their families. They may receive a few days of training on assignments and be requested to get involved in many other health programmes as well. Traditional birth attendants (TBAs). They have been a part of the rural community for a very long time and provide services to women during pregnancy, delivery and postpartum. They also often provide household assistance to the families and make home visits. Most of the older TBAs are illiterate and have joined the service because others in the family have been TBAs. In some countries, the majority of poor women empathized with TBAs and preferred to have their deliveries done by them at home rather than at the health facilities that often lack infrastructure and do not provide women-friendly services. Major issues related to TBAs include unsafe practices and high maternal and newborn fatality rates when complications/problems occur during childbirth. However, they have better accessibility and command the trust of the community, especially women from the lower socioeconomic groups.
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20. This category of the workforce has the advantage of reaching out to the most vulnerable segments of the community. They are well regarded by these communities and accorded the respect given to elderly or important community members because of their understanding of the socio cultural aspects of the community. However, it is well recognized that professional or skilled care at birth is critical for both mothers and their newborns. Effective midwifery ensures non-traumatic birth and reduces maternal and neonatal mortality and morbidity through appropriate actions and immediate referral when complications/problems occur. 21. Recognizing the important roles of TBAs in backward communities, while at the same time promoting human rights to secure the best possible health care for all regardless of their socio economic status, many countries have initiated collaboration between SBAs and TBAs. These 5
Comprehensive emergency obstetric care requires ability of a referral hospital to provide care and treatment for major obstetric complications, including performing caesarian section and provision of blood transfusion.
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countries aim to shift the technical aspects of childbirth as the responsibility of SBA’s while TBAs have to take care of the socio cultural and domiciliary aspects. This collaboration can be done before, during and after childbirth, with TBAs assisting SBAs. Financial compensation is provided by the SBAs to the TBAs for assisting the former.
Key initiatives in countries for improving human resources for MNH 22. The expansion of community-based midwifery-trained health personnel is one of the key strategies to improve access to MNH services for those who need them the most. It is necessary to ensure that these skilled health workers are supported and reasonably rewarded in financial terms. Some countries have made significant effort to make them available to all families. For example, Indonesia has produced and deployed – between 1989 and 1996 – more than 54 000 community-based midwives operating at the village level who were also allowed to open a private clinic while they were part of and supervised by the public health system and by their professional bodies. In Thailand, nurse-midwives can also open midwifery clinics to provide midwifery services. 23. Since 2004 Bangladesh has provided training for female health staff at the community level in select skills to provide antenatal care, normal births, postpartum and newborn care; and recognize and refer complications. Though the community-based skilled birth attendants do not yet meet the definition of a skilled attendant, this approach is an interim step forward and reflects the Government’s commitment towards reducing maternal and neonatal mortality. Supervision of the new cadre of skilled attendants is seen as an important step in ensuring quality of services. 24. Nepal has formulated a roadmap for the production of SBAs by developing an in-service training strategy for 2006–2012. The existing auxiliary nurse midwives (ANM) and MCH workers in the health system will be upgraded as SBAs with appropriate skills. As a long-term measure, initiative has been taken to review the ANM curriculum and update this by incorporating appropriate SBA skills in their pre-service education. Timor-Leste is working on the development of the curriculum for a new course leading to a Diploma in Midwifery. Earlier in the late 1990s, Indonesia converted the one-year midwifery pre-service training into a three-year diploma programme. 25. Policy and strategy related to the MNH programme is available in all countries, although sometimes it is a part of reproductive health strategy. India, for example, launched the National Family Planning Programme in 1951. This gradually evolved to family welfare, child survival and safe motherhood, and the Reproductive and Child Health Programme, and it is now under the preview of the National Rural Health Mission. Maldives has a National Reproductive Health Strategy and Sri Lanka has a Maternal and Child Health Policy and Strategy Framework (2006). Other countries of the Region also have similar policies and strategies in phase. These policies encourage the presence of skilled attendants at birth. 26. Regarding the national workforce plan, Thailand launched the National Health Workforce Plan in March 2008. Bangladesh, DPR Korea, Maldives, Nepal and Timor-Leste are reported to have workforce plans in place but some have not been implemented, partly or fully, yet. Due to
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the high MMR and NMR, Bangladesh and Nepal have developed a health workforce policy and plan focusing on MNH service. Meanwhile, Maldives will implement the SBA policy in 2015.
WHO resolutions, strategies and tools 27. Advocacy using the World Health Report 2005: Make every mother and child count and the technical discussions on Skilled Care at Every Birth carried out during the 42nd CCPDM Meeting of the SEA Region in 2005 has led to the endorsement of a resolution (SEA/RC58/R2) at the 58th Session of the Regional Committee in 2005. It urges Member States, among others, “to review the gaps in human resources for skilled care at birth and, as appropriate, to develop or modify human resource policies for skilled care at birth, which includes planning, production, placement, retention and career development”. It also requests the Regional Director, among others: “to enhance technical support to Member States in reviewing and revising their human resource policies, strategies and plans, and assist in their implementation to achieve skilled care at every birth”. 28. Earlier in 2004, the Regional Office had published the Strategic Directions to Improve Newborn Health in the South-East Asia Region, which was utilized by Member Countries in bolstering efforts to improve newborn health. The importance of skilled care at birth and the crucial role of SBAs at the community level for improving newborn health, as well as maternal health, were emphasized. 29. A tool for strengthening midwifery, the WHO/ICM Midwifery Tool kit, has been developed. It includes, among others, strengthening of pre-service midwifery training and in-service midwifery supervision. It has been introduced to all Member countries in the regional workshops in 2005 and 2007. The workshops basically touched upon strengthening human resources for MNH at the primary-care level through improving pre-service education to enhancing their performance in providing MNH care. A package of midwifery training modules has also been developed for pre-service education. 30. As a follow-up of the advocacy, SEA Region countries have invested considerable effort to achieve the MDG 5, which implies universal access to maternal and newborn health and other reproductive health services. However, the wide gaps between the goals and what have been achieved still exist. One of the main reasons for this is inadequate and incompetent human resources. Throughout the years, WHO has been providing technical assistance to Member States for capacity building of the workforce through various mechanisms that include meetings, conferences, trainings, study visits, field trips, formal education and the provision of standards, guidelines, tools and teaching materials. These aim to support countries in improving access to and quality of MNH services in the context of continuum of care and functioning health systems.
Key issues and challenges in human resources for MNH 31. The key issues and challenges in human resources for MNH include those at the policy level and the entire working lifespan levels from entry, workforce and exit.
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Policy level (1) Lack of a clear policy and plan on human resources for MNH services in most countries is a challenge. This is combined with inadequate knowledge of and skills on human resources in various categories and lack of analysis of the workforce in each category for planning purposes. The strength of the workforce is usually available at the country level; however, the standard of each category to population, and its analysis are not available in most countries. It is, therefore, difficult to identify the level of shortage of human resources for MNH, although it is obvious that the number of SBAs, particularly at the community level, is inadequate. Inadequate number of SBAs, especially at the community/primary health-care level, and specialists due to inadequate production levels and paucity of posts is a major challenge. Bangladesh, India and Nepal are working towards increasing the number of SBAs through upgrading the midwifery skills of the existing primary health-care providers for MNH, i.e. ANMs, FWAs and HAs. However, the duration of competency-based midwifery training, especially in assisting normal delivery, currently varies among the countries: it is six months in Bangladesh and Nepal but only three weeks in India. This wide variation in midwifery training results in differing levels of programme effectiveness and in creating SBAs of uniform competence. Other policy issues are related to the three stages of working lifespan as elaborated below.
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Entry: Preparing the workforce (1) The existing pre-service nursing and midwifery curriculum and teaching methods could not produce SBAs as expected: this is due to the poor curriculum, lack of qualified midwifery teachers, clinical instructors and inadequate infrastructure, i.e., the clinical sites for midwifery training. Recruitment and distribution of human resources for MNH: It is necessary to get workers with the right skills to the right place at the right time and achieve better social compatibility between workers and clients. In India, Indonesia and Thailand, the local government has been involved in the recruitment and placement of staff working at the community/primary health-care level. In addition to inadequacy in numbers and category, there are gaps in sanctioned versus filled-up posts for almost all categories of the health workforce in Bangladesh, India and Nepal. While the number of SBAs at the community level is inadequate, the number and distribution of specialists for MNH are most uneven, with the large cities being at an advantage. Difficulties in recruitment, deployment and retention of human resources for MNH in remote areas are often due to the poor working environment, low incentives and inadequate budget for posts.
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Workforce: Enhancing worker performance (1) Poor working environment, especially for those working at the district and community levels. This includes poor infrastructure, lack of clean water, unsafe environment,
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inadequate equipment, few opportunities for in-service training or continuing education, low salary/incentives and poor career development. (2) Excessive workload of MNH providers at the community level coupled with other primary health-care work not related to MNH care, which usually results from an inadequate workforce or on account of vacant posts. In countries with a high MMR and a low proportion of deliveries assisted by skilled attendants, it is necessary to have health providers at the community level who have the necessary skills and are dedicated to MNH care. Inadequate supervision and monitoring system, as well as system supports for MNH providers, especially those at the community level. These and other contributing factors, such as lack of a reward system and the poor working environment, affect the performance of MNH providers.
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Exit: Managing attrition (1) Lack of data on national turnover rate for each category. There is a minimal internal migration from the public to the private sector. However, the majority of the workforce, especially nurses and doctors, who resigned from their posts in some countries went to such employment in other countries. In order to minimize the turnover rate of nurses, a local government organization in Thailand has been collaborating with the Faculty of Nursing in the recruitment of local students to study nursing, supporting their education and hiring the successful graduates to work in the villages. As of today, this initiative has become a policy of the Ministry of Public Health and many local government organizations follow. Lack of retirement planning. Succession planning is important in preserving key competencies and skills in the workforce.
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The way forward for Member States and the role of WHO 32. Considering the regional situation and the above key issues and challenges, the following includes the proposed steps forward for Member States and the role of WHO in assisting them.
The way forward for Member States 33. The following recommendations are proposed for consideration to improve the management of human resources for accelerating the reduction of maternal and neonatal mortality.
At the policy level (1) Strengthening of national database on human resources for MNH classified by category. The data is to be analyzed against an agreed standard for identifying human resource gaps in each category at the sub national level. Development of a long-term national plan on human workforce for MNH to address the gaps for each category and ensure adequate resources and effective plan implementation.
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This should be linked to the efforts in accelerating the achievement of MDG 5 on improving maternal health and pregnancy outcomes by 2015. (3) Strengthening human resource management for MNH service, which includes proper planning, production and deployment, job description, monitoring and supervision, retention, cutting waste, incentives and career development for each category. Working with partners, NGOs and stakeholders in the development of a clear policy and plan on skilled birth attendants, especially those at the community level when the MMR is high and proportion of delivery assisted by skilled birth attendants is low (below 50%). This should aim to scale up the training and production of midwives/nurses-midwives and/or upgrade the existing MNH providers at the community level and adequately distribute this workforce in the needed areas.
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At the entry level for preparing the workforce (1) Building strong institutions for education. This is essential to secure the numbers and qualities of health workers required for accelerating the reduction of maternal and neonatal mortality. This includes investment in strengthening the nursing and midwifery schools, teachers and infrastructure to support midwifery curriculum development, capacity building of teachers, improvement of infrastructure and training sites, especially when MMR and NMR are high and the proportion of deliveries assisted by skilled birth attendants is low. Assuring educational quality that involves institutional accreditation and professional regulation (licensing, certification or registration). Rapid growth of the private sector in education in some countries should lead to strengthening of the government mechanism to regulate the quality of education. Revitalizing recruitment capabilities. Institutional weaknesses related to recruitment information and effective deployment needs serious attention. It is necessary to get workers with the right skills to the right place at the right time and achieve better social compatibility between workers and clients in terms of gender, language, ethnicity and geographical location.
(2)
(3)
At the workforce level for enhancing performance (1) Bolstering a supervision system that is supportive, firm and fair in order to improve the competence of individual health workers. This can be the most effective instrument when coupled with clear job descriptions and feedback on performance. Ensuring fair and reliable compensation. Adequate pay that arrives on time is crucial. Financial and non-financial incentives are more effective when carefully packaged than when provided on their own. Strengthening critical support systems, including security, availability of clean water, adequate lighting, heating, adequate financial mechanism, vehicles, medicine, supplies, basic equipment and effective referral back-up.
(2)
(3)
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(4)
Ensuring lifelong learning in the workplace, including peer group meeting/sharing experiences, short-term/on-the-job training, encouraging staff innovations and fostering teamwork. Improving collaboration between MNH health providers at the community level and informal heath providers, including community health volunteers and TBAs.
(5)
At the exit level for managing attrition (1) (2) Managing migration of health workers by balancing the freedom of individuals with the need to stem excessive losses from internal and international migration. Enhancing retirement planning. Succession planning is crucial in preserving key competencies and skills in the workforce. Unwanted attrition can be reduced by a range of policies, i.e. reduce incentives for early retirement, recruit retirees back to work and improve conditions for older workers.
The roles of WHO (1) Advocate for increasing investment in human resources for MNH and work together with Member countries at the policy level, i.e., in pioneering national plans for scaling up effective strategies on human resources for MNH and strengthening educational institutions. Assist Member countries in bolstering human resource management for MNH service, which includes improvement in production and deployment, cutting waste, retention, incentives and career development, as well as ensuring adequate number and quality of skilled birth attendants, appropriate job descriptions for them, and their effective monitoring and supervision. Promote the use and implementation of evidence-based policies, standards and tools for improving human resources for MNH. Facilitate collaboration among stakeholders that includes governments, development partners, donor agencies, academia, professional organizations, NGOs and other relevant parties to address the issues and challenges of human resources for MNH. Catalyze knowledge and learning exchange and support studies/research in the areas of human resources for MNH, including the socio cultural aspects of provision of MNH care for rural and disadvantaged communities.
(2)
(3) (4)
(5)
Suggested further reading (1) (2) (3) The World Health Report 2006. Working together for health. Geneva, World Health Organization, 2006. The World Health Report 2005. Make every mother and child count. Geneva, World Health Organization, 2005. Skilled Care at Every Birth. Report and Documentation of the Technical Discussions held in conjunction with the 42nd Meeting of CCPDM, Dhaka, 5–7 July, 2005. New Delhi, World Health Organization, Regional Office for South-East Asia, 2005.
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(4) (5) (6) (7) (8) (9)
Improving Maternal, Newborn and Child Health in the South-East Asia Region. New Delhi, World Health Organization, Regional Office for South-East Asia, 2005. Tracking Progress in Maternal, Newborn and Child Survival: The 2008 Report. Countdown to 2015: Maternal, Newborn and Child Survival. UNICEF, 2008. Making pregnancy safer: the critical role of skilled attendants. A joint statement by WHO ICM FIGO. Geneva. World Health Organization 2004. Strategic Directions to Improve Newborn Health in the South-East Asia Region. New Delhi, World Health Organization, Regional Office for South-East Asia, 2004. Maternal Mortality in 2005. Estimates developed by WHO, UNICEF, UNFPA and the World Bank, 2007 Neonatal and Perinatal Mortality: Country, Regional and Global Estimates 2004. WHO, 2007.
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Annex 1
Categories and number of human resources for MNH Country BAN BHU Health assistant General nurse-midwife Doctor, specialist DPRK Nurse midwife Midwife Doctor, specialist IND (2006) Multipurpose health worker (Male) Multipurpose health worker (ANM) Health assistant (Male) Health assistant/Lady health visitor Nurse midwife Doctor Specialist INO Midwife Nurse Doctors, specialist MAV Family health welfare Community health worker Nurse-midwife Doctor Specialist MMR Auxiliary midwife Midwife Lady health visitor Health assistant Nurse Doctor NEP FCHV Maternal child health worker ANM Nurse Doctor Specialist 28 872 17 703 3137 1778 21 075 27 750 48 352 3275 1657 1126 634 180 x x x x x HP,DCC PHCC PHCC SHP x x Village Dev x x x 65 511 149 695 18 223 17 107 29 493 22 273 3979 x x x x x x HC, HP, Family Health sections HC, HP PHC PHC CHC, PHC PHC CHC, PHC x x x x x PHC PHC PHC x x x x PHC Categories Number Hospital Primary health care facilities Community
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Country SRL
Categories Public health midwife (PHM) Medical officer MCH (MO-MCH) Midwife Nursing officer Medical officer Specialist Supervisors and managers
Number 4654 342 24
Hospital
Primary health care facilities
Community x 1:300–5000
MCH clinics x x x x x x x PHC
x
2723 15 797 99
THA
Nurse-midwife Doctors Specialist
TLS Source: Country report 2007
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Annex 2
Educational background, programme of study and duration of programme of selected human resources for MNH Categories FCHV MCHW Family health worker Community health worker (midwifery) Multi purpose workers (ANM) PHM Health Assistant Lady health visitor Staff nurse 8–10 class pass GCE O’ level 3 passes GCE O’ level 3 passes Maternal Child Health Workers Programme Certificate in Family Health Workers Certificate or Diploma in Primary Health Care 3 months 1 year 18 months or 30 months (conversion 6 months) 18–24 months 18 months 18 months 1 year 3 years Basic education requirement Programme of study Duration of programme
Grade 10 GCE (advanced) Grade 10 ANM SLC
Auxiliary Nurse Midwife Public Health Midwife Certificate in Health Assistant Certificate in LHV Proficiency Nursing Programme, Certificate or Diploma in Nursing/Midwifery Bachelor of Science in Nursing Post basic Master’s programme; Maternal and Child Nursing, Midwifery, Neonatal Nursing PhD Certificate in Midwifery Certificate in Midwifery MBBS
Grade 12, GCE O’ level 3 passes Grade 12 GNM BSc, Post-basic Master’s Midwife Medical doctor GCE (Advanced level) Diploma in Nursing Grade 12 GCE A’ level 3 passes
3 years 4 years 2 years 2–3 years 3 years 18 months 6 months – 1 year 5 years 5 ½ years plus 1 year internship 6 years plus
Specialist
MBBS
MD in obstetrics and gynecology; paediatrics
2–3 years
Source: Country Report 2007