SoWMy country briefs: Methodology

This presentation describes the key methodology and data sources used in the SoWMy 2014 report and the country briefs. It is aimed at teams preparing country launches or advocacy efforts using the SoWMy report.

SoWMy briefs: overview Future need Current need Future availability Availability Effective coverage today Quality Accessibility

Sources of data Data from effective coverage modelling (ICS Integrare) Data from secondary sources (UN Pop) Data from pregnancy modelling (ICS Integrare, U. of Southampton) Data from secondary sources (WHO) pregnancies births Data from effective coverage modelling (ICS Integrare) Data from SoWMy survey Data from SoWMy survey Data from SoWMy survey Data from secondary sources (DHS)

Exploring availability na = there is no cadre in this category providing MNH services in the country - = no information available In this section of the brief, health workers are grouped into general categories based on countries’ own category choice in the SOWMY survey. Workforce numbers are based on the responses to the SoWMy 2014 survey. Where the country could not provide any data, figures from the WHO Global Health Observatory, or from national policy documents were used. It’s very important to know not just how many health workers there are, but also how much of their time they spend on providing MNH services. The SoWMy survey asked countries to report on the % time spent on MNH by each cadre . Multiplying this % by the total number of workers is used to obtain the “full time equivalent” workers in MNH – or FTE. See Footnote 1 for details on which country cadres are included in each category of MNH workers! Example footnote page 67: These health worker categories include the following country titles - Midwives: includes obstetricians, obstetric nurses; Nurses: includes generalist nurses, family health nurses, specialized nurses, nurse technicians; Auxiliary nurse-midwives: includes nursing assistants; Generalist physicians: includes general practitioners, general surgeons, family health doctors; Obstetricians & gynecologists: includes obstetric doctors and gynecologists.

Calculating met need in the present The model which calculates met need works in three steps: Estimating the workforce requirements that are needed. How many health workers are needed to provide the package of MNH services that women and newborns need? This package is set as 46 essential interventions recommended by PMNCH. The model estimates how to provide these interventions to the population at the level of universal coverage (meeting 100% of need). The calculation works in 2 steps: How much time is needed to deliver an intervention to a single woman or newborn? How many women or newborns need this intervention? This depends on: Demographic characteristics: the number of women of reproductive age, pregnancies and births in the population; and Epidemiological characteristics: the particular epidemiological profile of a country (e.g. prevalence of malaria, HIV/AIDS, etc). 2. Estimating the workforce availability that the country actually has to provide these MNH services. This is based on the data that the countries reported on FTE health workers in the country (the number of health workers multiplied by the % time they spend on MNH). These are then converted into total hours of available working time (assuming that each worker works 40 hours a week, gets 4 weeks holiday, and spends 70% of working time on clinical tasks). AWT is then assigned to providing the set of essential interventions. The AWT is only counted towards meeting workforce time needed for an intervention if the cadre is in theory sufficiently skilled to deliver that intervention, based on the roles and competencies of each cadre of health worker according to official WHO guidelines. More details on the modelling methodology are available in Annex 3 on pg. 209 of the report! 3. Finally, to estimate the ”met need” is a simple calculation of the difference between the workforce required and the workforce that is available.

PMNCH Essential Interventions The 46 essential interventions recommended by the Partnership for Maternal, Newborn and Child Health cover the whole continuum of MNH care – from pre-pregnancy, to antenatal, to childbirth, to postnatal care. Available at: http://www.who.int/pmnch/knowledge/publications/201112_essential_interventions/en/ More details on how the need for each intervention was estimated shown in Annex 4 on page 212 of the report!

PMNCH Essential Interventions

Estimates and projections to 2030 To calculate future met need, the model looks at how the current stock of the workforce will evolve between 2012 and 2030. The model takes into account: the outflows from the workforce (due to death, voluntary attrition, and retirement). the inflows into the workforce (from new graduates who enter each year) The resulting projected workforce is the difference between the inflows and outflows.

ISCO Classification Health workers classified according to country titles Health workers re-classified according to ISCO For all calculations of met need, health worker cadres given by the countries were reclassified into categories according to the international standard of classifications (ISCO-08). This reclassification is based on the roles and responsibilities that the countries reported in the SOWMY questionnaire for each cadre. This results in some cases in workers “changing category” – for example, a cadre that is titled in the country as a “midwife” may be reclassified as a Midwifery associate professional , or auxiliary, according to ISCO code, if they do not perform all the essential roles and responsibilities of midwives. The reclassification allowed us to create a model that would work across different countries, which have very different ways of naming health workers, and to provide an accurate estimate of met need based on the actual roles and responsibilities of each cadre.

Projections of met need to 2030: Current trajectory The brief shows the projections of met need to 2030 if the current trajectory is maintained. Need: total FTE MNH workers needed to provide the 46 essential interventions to the population at the level of universal coverage Available workforce: total FTE MNH workers with the skills available to provide the needed set of essential interventions

What if… trajectory The final section of the brief shows the gains in met need by 2030 if 4 potential policy scenarios are implemented. What if…

Projections of met need: issues for policy discussion The met need estimates are national aggregate measures of workforce availability, based on the best available evidence provided by the countries in the SOWMY survey. Some indicative policy questions for discussion with national stakeholders: Are the projections of inflows into the workforce likely to be realized as planned? Can new evidence/data be obtained to improve the accuracy of the met need estimates? What evidence is available on the other dimensions of effective coverage: accessibility, acceptability, quality?

Data requirements for met need modelling 10 minimum pieces of data are needed to provide accurate estimates of met need: Headcount Enrollments into education % time spent on MNH Attrition from education Roles and responsibilities Graduates from education Age distribution Voluntary attrition from the workforce Retirement age Length of education Default assumptions: Annex 5 contains default assumptions for all 10 required pieces of data For example: the default assumption for attrition (if data is missing or inconsistent) is 4% More than 50% of cadres did not have/provide attrition information, meaning this default assumption (4%) was used in its place. Source: SoWMy 2014, pg. 14

Effective coverage CRUDE COVERAGE EFFECTIVE COVERAGE AVAILABILITY ACCESSIBILITY ACCEPTABILITY QUALITY Midwifery workforce is AVAILABLE? Midwifery workforce is ACCESSIBLE? Midwifery workforce is ACCEPTABLE? Midwifery workforce provides QUALITY CARE? The evidence and analysis in SoWMy 2014 is structured by the four domains that determine whether a health system and its health workforce are providing effective coverage, i.e. whether women are obtaining the care they want and need in relation to SRMNH services. These four domains are: availability, accessibility, acceptability and quality. The concept of “effective coverage” was developed by T. Tanahashi and the WHO in the 1970s to explore the delivery of health services. General Comment No. 14 on the right to health, published in 2000, mirrored the Tanahashi domains of availability, accessibility and acceptability with quality as the fourth domain (AAAQ). The use of the effective coverage framework to explore human resources for health is enabling new policy insights across countries. A midwife is available in or close to the community As part of an integrated team of professionals, lay workers and community health services Woman attends A midwife is available As needed Financial protection ensures no barriers to access Woman attends A midwife is available As needed Providing respectful care Woman attends A midwife is available As needed Providing respectful care Competent and enabled to provide quality care. Source: Campbell J. SoWMy 2014 Met need estimates are based on the dimension of availability

Accessibility: example issues for policy discussion Financial accessibility: Can the population afford to access the services of MNH workers? In theory, minimum health benefits packages are available free of charge at the point of service. To what extent is this the case in your country? Source: SoWMy 2014 survey Geographical access: is the available MNH workforce equitably distributed within the country in relation to need? Source: DHS

Quality: example issues for policy discussion What is the actual quality of the care being provided by MNH workers? Source: SoWMy 2014, pg. 32 The country briefs include information on education, regulation, association (ERA) – these are the enabling environment for the midwifery workforce to provide quality care Note this figure uses a proxy for quality of care: >25 supervised births in curriculum Source: SoWMy 2014 survey

Further information The SOWMY helpdesk is here to help! For any queries, send us an email at: sowmy2014@socialbase.org Thank you!