1 human resources for maternal health and task-shifting january 6 th, 2010 woodrow wilson center...
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Human Resources for Maternal Health and Task-Shifting
January 6th, 2010
Woodrow Wilson CenterWashington, DC
Seble Frehywot MD, MHSAAssistant Research Professor of Health Policy and Global Health
The George Washington University
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Outline
Current Human Resources for Health (HRH) status for maternal health
Types of task shifting
Regulation of task shifting and expanded service roles
Key lessons learnt from the "WHO Task-shifting Recommendation and Guidelines”
Key future challenges and strategies
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World Workforce & Health Status: The Global Picture
SOURCE: JLI 2004./ WHO 2006 World Health Report
< 23 HCP/10,000 unlikely to achieve MDG
2 physicians/10,000 11 nurses and mid wives/10,000
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Maternal Mortality Ratio (per 100,000 live births) and Regional Averages
Source: WHO (2005). The World Health Report 2005 – Make Every Mother and Child Count. Geneva, World Health Organization
Source: for Regional Averages : WHO: World Health Statistics 2009
AFRO900
SEARO450
AMRO99
EMRO
420
WPRO82
EURO27
The average global Maternal Mortality Ratio of 400 maternal death per 100,00 live births in 2005 has barely changed since 1990.
Source: for Regional Averages : WHO: World Health Statistics 2009
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Global Causes of Maternal Mortality and the Need for Skilled Workforce
Hemorrhage25%
Infection15%
Eclampsia12%
Obstructed Labor7%
Unsafe Abortion13%
Other Direct Causes8%
Indirect Causes20%
Source: World health Report, 2005
**Good quality maternal health services are not universally available
and accessible
** > 35% receive no Antenatal Care
** ~ 50% of deliveries unattended by skilled provider
** ~ 70% receive no postpartum care during 1st 6 weeks following delivery
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Health Workers Save Lives
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Too Many Preventable Deaths!!...
Source: WHO (2005). The World Health Report 2005 – Make Every Mother and Child Count. Geneva, World Health OrganizationSource: for annual numbers : WHO: World Health Statistics 2009
Annually, 536,000 women die of pregnancy related
complications 99% in developing countries
(1 per minute)~ 1% in developed
countries
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Task Shifting Types
Task shifting I
Task shifting II
Task shifting III
Task shifting IV
Specialized Physicians
Doctors
Non-physician clinicians(clinical officers, health officers)
Registered Nurses& nurse mid-wives
Nursing Assistants
&Community Health Care
Worker
Enrolled nurses
Expert Patients
REGULATIONSupervision, Delegation,
Substitution,Enhancement, Innovation
Task shifting 0
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Expanded Service Roles (ESR)(Example TS I)
Medical Doctor Non-physician Clinicians(e.g. AMO, Clinical Officers, Health Officers)
Diagnostic, PrescriptiveCase Treatment and
Management Authority
Delegation or Supervision
Pre-service training coupled with additional in-servicetraining
Expanded Service Roles (ESR)
SOP include:
Medical care and management, OBGYN (C/S), minor Surgery, Anesthesia,
Orthopedics, Ophthalmology, Dermatology etc.
Reg
ula
tory
Fra
mew
ork
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Expanded Services Role (ESR)TS0 and TS I
ESR from specialists to GPs
- C/S, management of complicated cases
ESR and NPCs
- C/S, management of complicated cases
Matching tasks needed with competency
Review of curricula to reflect the need on the ground
Buy-in from professional associations
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Expanded Services Role (ESR)TS III—TBA, CHWs
Traditional Birth Attendants---Community based, community women
comfortable with them
Limited technical skills
Need adequate training, supervision and supplies
Tasks--ESR
Antenatal care
- Risk screening…..train to identify risk cases earlier on and refer
to higher care site
- Motivate/empower not to keep women away from life-saving
interventions due to false reassurance
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Scope of Practice & Competencies
Standards of Care
Standard Pre-ServiceEducation & Training
Licensing & Registration &
Certification
StandardIn-Service Training &
Certificate
Recruitment, Deployment, Promotion, Salary, &
Other HR Issues
Working Conditions
Supervision/Mentoring & Accountability
Health CareWorkers
Financing &Sub-national
Implementation
1
2
34
5
6
7
89
Professional Councils
MOH
Professional Practice Acts
Professional Councils,Professional Associations,
MOHNormative Bodies (WHO)
MOE, MOHTraining Institutions,
Professional Councils,Professional Associations
Professional Councils, MOH
MOH. MOE,Training Institutions,
Professional Councils Professional Associations
Public Service Agency,
MOH,MOF, IMF,Local Government,
Professional Association
MOL, ILO,MOH,Professional Association,
Local Government
MOF, Local Government,MOH, IMF, WB
Professional Council, MOH, Other Health Care Providers
Maternal Health Treatment and Care Policies & Guidelines
Labor Policies
Regulating HCWs and Who is Involved?
Decentralization Policy
Civil Service Policies
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Types of Regulation
Laws and statutes
Regulations
Guidelines
General and specific maternal health care provider policies
Program guidance
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Why Develop A Regulatory Framework?
To build national and international support and commitment
To ensure quality and safety in the delivery treatment, care and prevention while task-shifting occurs
To promote the sustainability of task-shifting/task-reallocation practices Legal conditions and rights of practice Hiring and promotion policies and procedures Standardize remuneration and salaries
To guide the development of standardized education and training programs to support task-shifting/task-reallocation
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Lessons from the "WHO Task-shifting Recommendation and Guidelines”?
Adaptability of the TS R&G to other issues
Outlining/identifying task
Matching task with competency
Creating optimal skill mix
Developing regulatory framework to ensure quality and safety of care and services
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Challenges and Strategies
Not enough HCWs
No optimal skill-mix at different care-site levels
Competency not matching need on the ground
Buy-in for revision of curricula
Creating critical mass and retaining faculty/supervisors at different levels---quality/supervision
Decentralizing targeted tertiary care to District Hospitals
Retaining needed HCWs in needed geographical areas—retention and motivation policies
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Policies need to address interventions at needed levels
Regional Referral Hospitalsalso called
Tertiary Care Centers
Health Centers (Type A and B)also called
Primary (First)-Level Health Care Facilitiesor
Health Clinics
District Hospitalsalso called
Second-Level Health Care Facilitiesor
First-Referral Level Facilities
SOURCE: WHO (2005): WHO Recommendations for Clinical Mentoring to Support Scale-up Of HIV Care, Antiretroviral Therapy and Prevention in Resource-Constrained Settings.
Health PostsAlso called
Health Houses
CONCENTR
ATE O
N THESE 3
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Pregnancy is NOT a Disease
Global initiatives to scale up health workforce
The Question is Whom to train? Where will they be trained? How will they be trained? What will they be trained for? To work where will they be trained? How will quality & safety of service be ensured? How will they be retained in needed areas?
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Pregnancy is NOT a Disease
There is a tide in the affairs of (wo)men which, taken at the flood, leads on to fortune;
Omitted, all the voyage of their life Is bound in shallows and in miseries. On such a full sea are we now afloat;
And we must take the current when it serves, or lose the ventures before us. “
William Shakespeare, Julius Caesar