1. Human Resources for Maternal Health and Task-Shifting January 6th, Woodrow Wilson Center Washington, DC
Seble Frehywot MD, MHSA
Assistant Research Professor of Health Policy and Global Health
The George Washington University

2. 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

3. World Workforce & Health Status: The Global Picture
< 23 HCP/10,000  unlikely to achieve MDG
2 physicians/10,000
11 nurses and
mid wives/10,000
SOURCE: JLI 2004./ WHO 2006 World Health Report

4. Maternal Mortality Ratio (per 100,000 live births) and Regional Averages
EURO 27
EMRO
420
AMRO 99
SEARO
450
AFRO
900
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
WPRO 82
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

5. Global Causes of Maternal Mortality and the Need for Skilled Workforce
**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
Source: World health Report, 2005

6. Health Workers Save Lives

7. Too Many Preventable Deaths!!...
Annually, 536,000 women
die of pregnancy related
complications
99% in developing countries
(1 per minute)
~ 1% in developed countries
Source: WHO (2005). The World Health Report 2005 – Make Every Mother and Child Count. Geneva, World Health Organization
Source: for annual numbers : WHO: World Health Statistics 2009

8. Task Shifting Types REGULATION Task shifting II Task shifting I
Non-physician clinicians
(clinical officers, health officers)
Task shifting III
Registered Nurses
& nurse mid-wives
REGULATION
Supervision, Delegation, Substitution,
Enhancement, Innovation
Enrolled nurses
Doctors
Nursing Assistants
&
Community
Health Care
Worker
Task shifting 0
Specialized Physicians
Task shifting IV
Expert Patients

9. Expanded Service Roles (ESR) (Example TS I)
Delegation or
Supervision
Medical Doctor
Non-physician Clinicians
(e.g. AMO, Clinical Officers, Health Officers)
Pre-service training coupled
with additional in-service
training
Regulatory Framework
Expanded Service Roles
(ESR)
SOP include:
Medical care and management, OBGYN (C/S),
minor Surgery, Anesthesia,
Orthopedics, Ophthalmology,
Dermatology etc.
Diagnostic, Prescriptive
Case Treatment and Management Authority 9

10. Expanded Services Role (ESR) TS0 and TS I
ESR from specialists to GPs
- C/S, management of complicated cases
ESR and NPCs
Matching tasks needed with competency
Review of curricula to reflect the need on the ground
Buy-in from professional associations

11. 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

12. Regulating HCWs and Who is Involved?
Professional Council, MOH,
Other Health Care Providers
MOF, Local Government,
MOH, IMF, WB
Professional Practice Acts
Supervision/Mentoring
& Accountability 9
Decentralization Policy
Financing &
Sub-national
Implementation 8
Professional
Councils
MOL, ILO,MOH,
Professional Association,
Local Government
Scope of Practice &
Competencies
Working Conditions
Labor Policies 1 7
Health Care
Workers
Maternal Health
Treatment and Care
Policies & Guidelines
Public Service
Agency,
MOH,MOF, IMF,
Local Government,
Professional Association
MOH
Recruitment, Deployment,
Promotion, Salary, &
Other HR Issues 2
Standards of Care
Professional Councils,
Professional Associations,
MOH
Normative Bodies (WHO) 6
Civil Service Policies
Standard
In-Service Training &
Certificate 5
Standard Pre-Service
Education & Training 3 4
Licensing &
Registration &
Certification
MOE, MOH
Training Institutions,
Professional Councils,
Professional Associations
MOH. MOE,
Training Institutions,
Professional Councils
Professional Associations
Professional Councils, MOH

13. Types of Regulation Laws and statutes Regulations Guidelines
General and specific maternal health care provider policies
Program guidance

14. 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

15. 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

16. 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

17. Policies need to address interventions at needed levels
Regional Referral Hospitals
also called
Tertiary Care Centers
District Hospitals
also called
Second-Level Health Care Facilities or
First-Referral Level Facilities
Health Centers (Type A and B)
also called
Primary (First)-Level Health Care Facilities or
Health Clinics
CONCENTRATE ON THESE 3
Health Posts
Also called
Health Houses
SOURCE: WHO (2005): WHO Recommendations for Clinical Mentoring to Support Scale-up Of HIV Care, Antiretroviral Therapy
and Prevention in Resource-Constrained Settings.

18. 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?

19. 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