Health Systems Strengthening for Equity (HSSE) The Power and Potential of Mid-level Providers HSSE team Supported by: Irish Aid & Ministry of Foreign Affairs, Denmark UNIVERSITY EDUARDO MONDLANE Faculty of Medicine

Partners to the Project Centre for Global Health, University of Dublin, Trinity College, Dublin (Eilish McAuliffe, Susan Bradley) Averting Maternal Death and Disability Program (AMDD), Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, USA (Lynn Freedman (Helen de Pinho, Samantha Lobis, Rachel Waxman and Sang Hee Won) Realizing Rights: the Ethical Globalization Initiative, USA ( Mary Robinson, Peggy Clark, Ibadat Dhillon, Naoko Otani) Regional Prevention of Maternal Mortality network, Accra, Ghana (Angela Sawyer, Dora Shehu) Ifakara Health Institute, Mikocheni, Dar Es Salaam, Tanzania (Godfrey Mbaruku, Honorati Masanja, Tumaini Mikindo, Neema Wilson, Debby Wason, Abdallah Mkopi, Aloisia Shemdoe) University of Malawi, College of Medicine, Centre for Reproductive Health, Malawi (Francis Kamwendo, Mwizapanyuma Simkonda, Wanangwa Chimwaza, Andrew Ngwira, Effie Chipeta, Linda Kalilani) Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Mozambique (Mohsin Sidat, Maria de Fatima Cuembelo, Sozinho Daniel Ndima)

Project objectives Research Advocacy Expand the evidence base in support of effective use of mid-level health workers within an enabling environment through the generation of new evidence and a critical analysis of existing evidence; Increase recognition and effective use of mid-level health workers among national, regional, and global policymakers to address the human resources crisis in district health systems based on project evidence; Advocate for an enabling environment that optimises performance of mid- level providers in order to strengthen health systems; and In partnership with African institutions, deepen local capacity to research and analyse human resource and health systems problems, develop innovative solutions, influence policymakers at local and global levels, and sustainably implement new strategies; and build the capacity of northern institutions to successfully engage in and support partnerships of this kind.

HSSE Study Parameters- Systems Approach

Data sources and methods At different levels Ministry – key informant interviews, documentary analysis Training bodies - key informant interviews, documentary analysis Regulatory bodies - key informant interviews, documentary analysis District level – District Health Information Survey Interviews with management team Facility inventory Provider survey – survey measuring job satisfaction, burnout, perceptions of justice, commitment to organisation, intentions to leave etc., Critical Incidents analysis – factors influencing decision to leave/stay.

Table 1:Facilities and Providers of EmOC CountryNo. of FacilitiesNo. of Providers Malawi84 (near national sample) 631 Mozambique Tanzania90811