1. “With Women” Midwives for Afghanistan Reproductive Health Workforce Development in Afghanistan 2002 - 2009 Jeffrey Smith, MD, MPH Asia Regional Technical Director Jhpiego

2. 2 Presentation Outline  Review the reproductive health situation in Afghanistan  Discuss the human resource constraints  Describe some key considerations in workforce development/task shifting in reproductive health  Present the results of interventions in Afghanistan

3. 3 RH Situation 2002  High maternal and newborn mortality (MMR 1600 / 100 000 LB)  Few RH providers  40% facilities with female staff  467 midwives in country  Non-uniformity of qualification  Out of date skills  No functional schools for training midwives – schools closed by Taliban  RH de-emphasized in medical curriculum  Disarray of system for supporting human resources for health  STRATEGY: support the education and deployment of large numbers of midwives rather than doctors

4. Task Shifting Putting clinical capability in hands of appropriate peripheral workers so that key components of health care can be diffused to greatest number of people. Should not be a temporary fix! But a professional focus! 4

5. 5 What works, who works, and where?  Health Center Intrapartum Care Strategy  Training of Midwives  Staffing of Health Centers  Health system linkages  Capability in Basic EmOC  Clarity about “skilled attendant”  Policy support for clinical authority  Educational system to achieve competency and capability Lancet 2006 Maternal Survival Series

6. 6 Workforce Assessment & Planning Array of semi trained, partially skilled workers NEEDHAVE Core group of leaders and academics Group of managers and teachers Bulk of personnel should be service providers Cries of crisis: “Something is better than nothing”

7. 7 Normatizing the Health Workforce  Re-establish health system accountability  Census of health workers  Including where they work  Testing: knowledge + skills  Phased (re)deployment  Registration and licensure  Upgrade programs  Education programs  Set selected practical policies  Immediate need and long term view  Emergency  Development Staff functioning as midwives Qualified License and Deploy Almost qualified Upgrade Standardize and Retain Unqualified Retrain to qualification, Redeploy

8. 8 Importance of Standardization  Single, standard approach to upgrading RH workforce may be more efficient, especially in post-conflict settings  Fragile health systems don’t have resources to compare and contrast different, non- uniform approaches at macro level  Uniformity of professional and community expectation, supervision, supply, etc.

9. 9 Policy and Structure  Basic Package of Health Services  Maternal Health / RH Service delivery guidelines  Guide for re-establishing services and in-service training/pre- service education  National MW education policy  Midwifery job description  Single, unified national midwifery curriculum  Assessment materials and criteria  of students  graduation and licensure  of clinical facilities  quality of care and clinical certification  of schools  school accreditation

10. 10 Standardization in Action  Standard curriculum and detailed teaching resources  National accreditation system  Based on “recipe” for establishing and running a midwifery school  Structured technical assistance framework  Increased local capacity and improved ability to support training programs and schools in remote or insecure areas

11. 11 Keep it clinical  Ensure that the focus remains on clinical skill development  MW program in Afghanistan was SHORTENED from 3 years to 2 and unnecessary topics were removed  Semester 1: Normal Pregnancy  Semester 2: Complications  Semester 3: Family Planning, RH and Child Care

12. 12 Keep it local  Retention, deployment, selection and education all related:  local control increases local commitment  Train midwives where they are needed  Focus on local, “micro- deployment”  Caveat: ensure adequate educational and clinical capacity

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14. 14 Results 2002 – 2009  5 midwifery schools re- opened and 26 new midwifery schools established  Midwifery deployment  1961 new midwives  85% deployed  86% working as midwives  Health centers with 1+ female health worker: 25%  83%  Health centers staffed with 1+ midwife: <10%  61%  Standardized system to improve quality in midwifery services and education

15. 15 Working as Midwives, 2009 ProgramCurrently studyingEnrolledGraduatedDrop-outs% GraduatedDeployed/Employed% Deployed/Employment ofgraduatedCurrently working(as of May, 2009)% currentlyworking ofgraduatedCurrently workingof deployed/employed IHS1671232110312990%89081%75468%85% CME5098868582897%78591%69481%88% Total6762118196115793%167585%144874%86% Local CME schools have greater success than regional IHS programs.

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17. 17 Deliveries by Skilled Attendants Selected Provinces/Districts Tarkhar: from 12% to 21% Herat: from 13% to 27% Examples of increase in skilled birth attendant coverage at birth:

18. 18 Professionalization of Midwifery Afghan Midwives Association  Founded in 2005  Provincial branch in most provinces  Roles:  Advocacy  Professional development  Networking and support  Has raised personal and professional stature of midwifery “This is the first time I have ever belonged to anything other than my own family. I feel proud to be a midwife.”

19. 19 Reflection on “Gender” Task shifting should not become Clinical Shortcutting Shortcuts in medical education vs. Shortcuts in midwifery education

20. 20 Conclusions  Vibrant maternal health / reproductive health workforce must be composed substantially of midwives  Midwives must be empowered professionally and deployed rationally  Consistency in the service delivery and educational system is essential for midwives to have skills and retain skills

21. 21 Acknowledgements  Ministry of Public Health, Afghanistan  Donors – USAID, World Bank and European Commission  Non Governmental Organization partners, WHO, UNICEF, and many other supporters of midwifery  Staff and students of all midwifery schools

22. 22 Thank you  Questions?  Comments?  Observations?