- Email: [email protected]
Evidence for action on improving the maternal and newborn health workforce: The basis for quality care
International Journal of Gynecology and Obstetrics 132 (2016) 126–129
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
EVIDENCE FOR ACTION
Evidence for action on improving the maternal and newborn health workforce: The basis for quality care Jim Campbell a, Laura Sochas b,⁎, Giorgio Cometto a, Zoë Matthews c a b c
Global Health Workforce Alliance, World Health Organization, Geneva, Switzerland Evidence for Action, Options Consultancy Services, London, UK Department of Social Statistics and Demography, University of Southampton, Southampton, UK
a r t i c l e Keywords: Accountability Evidence Health workforce Maternal mortality Midwifery Neonatal mortality Quality of care
i n f o
a b s t r a c t Ambitious new goals to end preventable maternal and newborn deaths will not only require increased coverage but also improved quality of care. Unfortunately, current levels of quality in the delivery of maternal and newborn care are low in high-burden countries, for reasons that are intimately linked with inadequate planning and management of the maternal and newborn health workforce. The Global Strategy on Human Resources for Health is a key opportunity to strengthen global and country-level accountability frameworks for the health workforce and its capacity to deliver quality care. In order to succeed, maternal and newborn health specialists must embrace this strategy and its linkages with the new Global Strategy for Women’s, Children’s, and Adolescents’ Health; action is needed across high- and low-income countries; and any accountability framework must be underpinned by ambitious, measurable indicators and strengthened data collection on human resources for health. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Ambitious new goals for maternal and newborn health
2. Quality of care: A necessary condition for accelerated progress
The Millennium Development Goals (MDGs) have been credited with generating attention and mobilizing resources for health development priorities, including in maternal and newborn health (MNH). A 45% decline in maternal mortality between 1990 and 2013 was achieved alongside a 24% decline in neonatal deaths [1]. The MDGs created a momentum for improvement: many individual countries will achieve their goals, while others are well on their way [2]. However, overall targets for women and children set by the Millennium Declaration will not be met and lag behind other goals [3]. The new Sustainable Development Goals (SDGs) will therefore need to ensure that further sustainable declines in mortality rates take place in the next decades. New proposed global targets to end preventable deaths are ambitious. New goals were agreed in April 2014 at a consultation with representatives from 30 countries, hosted by WHO, UNFPA, USAID, the Maternal Health Task Force, and the Maternal and Child Health Integrated Program (MCHIP) (Figs. 1 and 2). These targets suggest that, given sustained efforts, a global maternal mortality ratio (MMR) of 70 per 100 000 live births and a global newborn mortality rate (NMR) of less than 12 deaths per 1000 live births can be reached by the year 2030.
Evidence that improving quality of care is a necessary condition for accelerating the pace of progress toward these new targets is now overwhelming. Although expanding accessibility is still needed, greater access to poor quality care will not decrease morbidity and mortality effectively, as shown in a variety of contexts such as India [4], Nepal [5], and Uganda [6], and in cross-sectional analysis [7]. Furthermore, poor quality care also dissuades women from accessing care [8]. Historical analyses in Sweden, Europe, and the USA have shown that the professionalization of the midwifery profession coincided with significant drops in maternal mortality, while cross-country data show that only countries with systems for skilled professional birth attendance reduced MMR below 50 per 100 000 live births [7]. Further evidence compiled by the Lancet Series on Midwifery demonstrates that a competent and motivated midwifery workforce is associated with progress in quality of care and maternal and newborn survival [9]. Quality of maternal and newborn care remains poor in many countries. A recent WHO survey of secondary and tertiary facilities in 29 high MMR countries [10] found that maternal mortality was on average two to three times greater than what would be expected given a similar level of patient risk in a moderate MMR context, such as Mexico. Furthermore, an extremely high percentage of women in high mortality hospitals received the recommended interventions, suggesting a quality rather than a coverage problem. Countries such as the Dominican Republic have not been able to tackle their high
⁎ Corresponding author at: Options Consultancy Services, 58 St Katharine’s Way, London, E1W 1LB, UK. Tel.: +44 (0)20 7430 1900. E-mail address: [email protected] (L. Sochas).
http://dx.doi.org/10.1016/j.ijgo.2015.11.003 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
J. Campbell et al. / International Journal of Gynecology and Obstetrics 132 (2015) 126–129
Fig. 1. New targets for maternal mortality. Reproduced with permission from USAID [25].
MMR problems without tackling quality of care [11]. Underestimation of severity, vertical care, poor implementation, inadequate prevention of infection, and delays in providing care all play their part in keeping MMR unnecessarily high, as well as broader determinants such as delayed access to the facility, undernutrition and pre-existing anemia as possible explanatory factors. Improving quality—although clearly not the only key remaining challenge—should therefore be at the core of scaling-up maternal and newborn health services toward universal health coverage. As discussed by Hulton et al. [12] in this issue of IJGO, quality of care has several dimensions, including human resources, though many other aspects of quality care such as respectful care or clinical practice are channeled through health workers. Researchers have tackled the question of how to create a workforce capable of delivering quality MNH care within an enabling environment for many years. Much attention has been given to interim strategies such as task-shifting [13], and the possible contributions of voluntary health cadres [14]. However, the problems inherent in creating, deploying, building, and maintaining a
127
quality professional workforce for MNH are only just gaining the prominence they deserve [15,16]. Often, supposedly skilled birth attendants do not receive the required midwifery training [16] or do not have the relevant competencies [17,18] to assist at birth. Fig. 3 shows the scale of this mismatch using data collected by the State of the World’s Midwifery 2014 report [16] from 73 countries with the highest burden of maternal and child mortality across the world. It shows the 10-fold difference between the human resources that are available and skilled to provide reproductive, maternal, and newborn health (RMNH) care based on a headcount of RMNH-related staff, and the amount of time spent by “truly skilled” birth attendants on these tasks. A lack of attention to the need for teamwork between skilled health professionals has had obvious implications for quality care, as not all women require the same type of professional assistance when giving birth. The recent State of the World’s Midwifery’s “Midwifery 2030 Vision” and the Lancet series on midwifery both stress the importance of collaborative and supportive teams of health workers where each professional’s scope of practice is respected and supported [16,19]. The skills and competencies of the workforce, as well as collaborative working between midwives, nurses, obstetricians, doctors, and other health staff must clearly underpin any strategy to improve quality care. Unfortunately, the forward planning needed to put a quality workforce into place is often not a focus for policy. The scale of the human resources challenge if the new SDGs are to be realized is significant and not widely understood. Africa in particular faces persistent health challenges and a rising population, and so demand for health workers continues to outstrip supply [20]. Despite some progress in closing the workforce gap, 39 African countries are deemed to have a critical health worker shortage [21]. Achieving global health and development goals therefore depends on strengthening health workforces in Africa. 3. An opportunity for accountability and action toward the new Sustainable Development Goals As the new Sustainable Development Goals (SDG) have now been agreed, we should seize the opportunity to build an accountability framework and its accompanying indicator set that is capable of delivering improved quality MNH care with a stronger workforce. Unless urgent action is taken to address the shortage and uneven distribution of health workers, none of these new goals can be met. It is predicted that by 2030, an additional 10 million health workers will need to be trained and deployed in low- and middle-income countries. That is
Fig. 2. New targets for newborn mortality. Reproduced with permission granted by Elsevier from Lawn et al. [26].
128
J. Campbell et al. / International Journal of Gynecology and Obstetrics 132 (2016) 126–129
Box 1 Desirable principles underlying a new accountability framework that promotes a quality-oriented health workforce. Looking forward, we need a contemporary narrative and an accountability framework that support a paradigm shift for quality across several dimensions of health workforce governance, development, and management, including a need to move: • Beyond targeting only numbers of health workers to recognizing that their accessibility, acceptability, and particularly quality and performance are equally important; • Away from training approaches focusing only on clinical competencies, embracing the transformative education agenda; • Toward recognizing that health workers are not just “inputs” for the health system, but individuals who require an enabling and supportive practice environment; • Away from a silo approach, and toward an integration of services in a continuum of reproductive, maternal, newborn, child, and adolescent care across phases of life and places of care-giving; • Beyond a rigidly hierarchical organization of healthcare teams, and toward a team-based approach that fosters inter-professional collaboration, making the most appropriate and effective use of specialists, general practitioners, midwives, nurses, mid-level and community-based health workers, according to their respective competencies and roles. Fig. 3. The midwifery workforce and the quality gap. The amount of time spent by cadres who are meant to carry out all skilled birth attendant tasks and have in theory practiced at least 25 supervised births are used as a proxy for “truly skilled” birth attendants. Reproduced with permission from UNFPA [16].
Adapted with permission granted by Elsevier from Cometto et al. [27]. mechanisms, stimulate action, contribute to collaboration between countries and global partners, and focus policy actions and investment decisions where they are most required. This will require—above all—good data collection mechanisms that build on existing and emerging sources. In order to include the SDG indicators on workforce, international and national data on human resources for health need to be augmented. Accountability at the level of individual countries can galvanize action on workforce issues but not without the most basic data for monitoring and decision making. Action must be taken to improve our workforce data or this most critical aspect of quality will be missing from the development databases. A fundamental initial step is to strengthen systems for collection and analysis of relevant health workforce data; this needs to go beyond routine information on availability of health workers, and should also include evidence on geographical accessibility, employment status, gender, wage dynamics, quality, and workforce performance. Quality of care, although determined by multiple factors, can only be improved if the number of skilled workers is scaled up. Preventing maternal and newborn deaths depends upon it.
why governments have tasked WHO to develop a new Global Strategy on Human Resources for Health: Workforce 2030, which brings together the latest evidence and best practices from across the globe. As partners coalesce around the new Every Woman, Every Child Global Strategy, we have an opportunity to ensure synergy between partners and policymakers by bringing this initiative into alignment with the emerging Global Strategy on Human Resources for Health, which will be considered by the 69th World Health Assembly in 2016 [22]. Success will involve concrete recommendations under a single comprehensive framework on actions at international and national levels to strengthen health workforce governance and management for better quality of care, following the principles summarized in Box 1. Equally as important, indicators and priorities on a quality health workforce need to be driven by strong accountability mechanisms at country level where changes are actually made. Building a strong accountability framework for a workforce that delivers MNH quality care requires that the human resource needs of all health subsectors be considered together—joining up MNH advocates with specialists from other areas of health. Priority-setting will also need to include countries at all levels of development. The health workforce agenda is of global relevance, as recent evidence shows that countries at all levels of socioeconomic development face health workforce challenges in accelerating progress toward attaining and sustaining universal health coverage [9]. Moreover, there is in fact a single global health labor market for qualified professionals (such as gynecologists and obstetricians, but also for midwives and nurses), as shown by the attention given to international health worker migration [23].
Jim Campbell is the Executive Director and Giorgio Cometto is a Technical Officer at the Global Health Workforce Alliance. Laura Sochas is a Technical Advisor and Zoë Matthews is former evidence lead on the Evidence for Action program.
4. Enabling action through measurable targets and data on human resources for health
References
The SDGs commit us to “increas(ing) substantially…the recruitment, development training and retention of the health workforce” [24]. A measurable target associated with this goal will enable accountability
Conflicts of interest
[1] United Nations. Saving Lives, Protecting Futures. Progress Report on the Global Strategy for Women’s and Children’s Health 2010−2015. New York: United Nations; 2015. http://www.everywomaneverychild.org/images/EWEC_Progress_ Report_FINAL_3.pdf.
J. Campbell et al. / International Journal of Gynecology and Obstetrics 132 (2015) 126–129 [2] van Lerberghe W, Matthews Z, Achadi E, Ancona C, Campbell J, Channon A, et al. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. Lancet 2014;384(9949):1215–25. [3] United Nations. The Millennium Development Goals Report 2015. New York: United Nations; 2015. [4] Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet 2010;375(9730):2009–23. [5] Powell-Jackson T, Morrison J, Tiwari S, Neupane BD, Costello AM. The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal. BMC Health Serv Res 2009;9:97. [6] Ekirapa-Kiracho E, Waiswa P, Rahman MH, Makumbi F, Kiwanuka N, Okui O, et al. Increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study. BMC Int Health Hum Rights 2011;11(Suppl. 1):S11. [7] Graham W, Bell J, Bullough C. Can skilled attendance at delivery reduce maternal mortality in developing countries? In: De Brouwere V, van Lerberghe W, editors. Safe Motherhood Strategies: A Review of the Evidence. Antwerp: ITG Press; 2001. p. 97–129. [8] Van den Broek N, Graham W. Quality of care for maternal and newborn health: the neglected agenda. BJOG 2009;116(Suppl. 1):18–21. [9] Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014;384(9948):1129–45. [10] Souza J, Gülmezoglu AM, Vogel J, Carroli G, Lumbiganon P, Qureshi Z, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet 2013;381(9879):1747–55. [11] Miller S, Cordero M, Coleman AL, Figueroa J, Brito-Anderson S, Dabagh R, et al. Quality of care in institutionalized deliveries: the paradox of the Dominican Republic. Int J Gynecol Obstet 2003;82(1):89–103. [12] Hulton L, Matthews Z, Bandali S, Izge A, Daroda R, Stones W. Accountability for quality of care: Monitoring all aspects of quality across a framework adapted for action. Int J Gynecol Obstet 2016. [13] World Health Organization. WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task-shifting (OPTIMIZEMNH). Geneva: WHO; 2012. http://apps.who.int/ iris/bitstream/10665/77764/1/9789241504843_eng.pdf. [14] Lewin SA, Dick J, Pond P, Zwarenstein M, Aja G, van Wyk B, et al. Lay health workers in primary and community healthcare. Cochrane Database Syst Rev 2005(1): CD004015.
129
[15] UNFPA. State of the World’s Midwifery 2011: Delivering Health, Saving Lives. New York: UNFPA; 2011. http://www.unfpa.org/publications/state-worlds-midwifery2011. [16] UNFPA. State of the World’s Midwifery 2014: A Universal Pathway. A Woman’s Right to Health. New York: United Nations Population Fund; 2014. http://www. unfpa.org/sowmy. [17] Harvey SA, Blandón YC, McCaw-Binns A, Sandino I, Urbina L, Rodríguez C, et al. Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward. Bull World Health Organ 2007;85(10):783–90. [18] Hussein J, Bell J, Nazzar A, Abbey M, Adjei A, Graham W. The skilled attendance index: proposal for a new measure of skilled attendance at delivery. Reprod Health Matters 2004;12(24):160–70. [19] ten Hoope-Bender P, de Bernis L, Campbell J, Downe S, Fauveau V, Fogstad H, et al. Improvement of maternal and newborn health through midwifery. Lancet 2014; 384(9949):1226–35. [20] Campbell J, Dussault G, Buchan J, Pozo-Martin F, Guerra Arias M, Leone C, et al. A universal truth: no health without a workforce. Geneva: Global Health Workforce Alliance and World Health Organization; 2013. http://www.who.int/workforcealliance/ knowledge/resources/GHWA_AUniversalTruthReport.pdf. [21] World Health Organization. Joining hands for health workforce improvements: Ghana hosts consultation on new global health workforce strategy. http://who.int/ hrh/news/2015/hrh-improvements_ghana-consult/en/. Published 2015. Accessed September 2, 2015. [22] World Health Organization. Follow-up of the Recife Political Declaration on Human Resources for Health: renewed commitments towards universal health coverage. WHA67.24. Published 2014. http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_ R24-en.pdf. Accessed July 24, 2014. [23] World Health Organization. WHO Global Code of Practice on the International Recruitment of Health Personnel. http://www.who.int/hrh/migration/code/code_en. pdf?ua=1. Published 2010. Accessed September 2, 2015. [24] United Nations. Report of the Open Working Group of the General Assembly on Sustainable Development Goals. http://www.un.org/ga/search/view_doc.asp?symbol= A/68/970. Published 2014. Accessed September 2, 2015. [25] USAID. Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action. Washington, DC: U.S. Agency for International Development; 2014. https:// www.usaid.gov/sites/default/files/documents/1864/MCHVision.pdf. [26] Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every Newborn: progress, priorities, and potential beyond survival. Lancet 2014;384(9938):189–205. [27] Cometto G, Boerma T, Campbell J, Dare L, Evans T. The Third Global Forum: framing the health workforce agenda for universal health coverage. Lancet 2013;1(6): e324–5.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
EVIDENCE FOR ACTION
Evidence for action on improving the maternal and newborn health workforce: The basis for quality care Jim Campbell a, Laura Sochas b,⁎, Giorgio Cometto a, Zoë Matthews c a b c
Global Health Workforce Alliance, World Health Organization, Geneva, Switzerland Evidence for Action, Options Consultancy Services, London, UK Department of Social Statistics and Demography, University of Southampton, Southampton, UK
a r t i c l e Keywords: Accountability Evidence Health workforce Maternal mortality Midwifery Neonatal mortality Quality of care
i n f o
a b s t r a c t Ambitious new goals to end preventable maternal and newborn deaths will not only require increased coverage but also improved quality of care. Unfortunately, current levels of quality in the delivery of maternal and newborn care are low in high-burden countries, for reasons that are intimately linked with inadequate planning and management of the maternal and newborn health workforce. The Global Strategy on Human Resources for Health is a key opportunity to strengthen global and country-level accountability frameworks for the health workforce and its capacity to deliver quality care. In order to succeed, maternal and newborn health specialists must embrace this strategy and its linkages with the new Global Strategy for Women’s, Children’s, and Adolescents’ Health; action is needed across high- and low-income countries; and any accountability framework must be underpinned by ambitious, measurable indicators and strengthened data collection on human resources for health. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Ambitious new goals for maternal and newborn health
2. Quality of care: A necessary condition for accelerated progress
The Millennium Development Goals (MDGs) have been credited with generating attention and mobilizing resources for health development priorities, including in maternal and newborn health (MNH). A 45% decline in maternal mortality between 1990 and 2013 was achieved alongside a 24% decline in neonatal deaths [1]. The MDGs created a momentum for improvement: many individual countries will achieve their goals, while others are well on their way [2]. However, overall targets for women and children set by the Millennium Declaration will not be met and lag behind other goals [3]. The new Sustainable Development Goals (SDGs) will therefore need to ensure that further sustainable declines in mortality rates take place in the next decades. New proposed global targets to end preventable deaths are ambitious. New goals were agreed in April 2014 at a consultation with representatives from 30 countries, hosted by WHO, UNFPA, USAID, the Maternal Health Task Force, and the Maternal and Child Health Integrated Program (MCHIP) (Figs. 1 and 2). These targets suggest that, given sustained efforts, a global maternal mortality ratio (MMR) of 70 per 100 000 live births and a global newborn mortality rate (NMR) of less than 12 deaths per 1000 live births can be reached by the year 2030.
Evidence that improving quality of care is a necessary condition for accelerating the pace of progress toward these new targets is now overwhelming. Although expanding accessibility is still needed, greater access to poor quality care will not decrease morbidity and mortality effectively, as shown in a variety of contexts such as India [4], Nepal [5], and Uganda [6], and in cross-sectional analysis [7]. Furthermore, poor quality care also dissuades women from accessing care [8]. Historical analyses in Sweden, Europe, and the USA have shown that the professionalization of the midwifery profession coincided with significant drops in maternal mortality, while cross-country data show that only countries with systems for skilled professional birth attendance reduced MMR below 50 per 100 000 live births [7]. Further evidence compiled by the Lancet Series on Midwifery demonstrates that a competent and motivated midwifery workforce is associated with progress in quality of care and maternal and newborn survival [9]. Quality of maternal and newborn care remains poor in many countries. A recent WHO survey of secondary and tertiary facilities in 29 high MMR countries [10] found that maternal mortality was on average two to three times greater than what would be expected given a similar level of patient risk in a moderate MMR context, such as Mexico. Furthermore, an extremely high percentage of women in high mortality hospitals received the recommended interventions, suggesting a quality rather than a coverage problem. Countries such as the Dominican Republic have not been able to tackle their high
⁎ Corresponding author at: Options Consultancy Services, 58 St Katharine’s Way, London, E1W 1LB, UK. Tel.: +44 (0)20 7430 1900. E-mail address: [email protected] (L. Sochas).
http://dx.doi.org/10.1016/j.ijgo.2015.11.003 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
J. Campbell et al. / International Journal of Gynecology and Obstetrics 132 (2015) 126–129
Fig. 1. New targets for maternal mortality. Reproduced with permission from USAID [25].
MMR problems without tackling quality of care [11]. Underestimation of severity, vertical care, poor implementation, inadequate prevention of infection, and delays in providing care all play their part in keeping MMR unnecessarily high, as well as broader determinants such as delayed access to the facility, undernutrition and pre-existing anemia as possible explanatory factors. Improving quality—although clearly not the only key remaining challenge—should therefore be at the core of scaling-up maternal and newborn health services toward universal health coverage. As discussed by Hulton et al. [12] in this issue of IJGO, quality of care has several dimensions, including human resources, though many other aspects of quality care such as respectful care or clinical practice are channeled through health workers. Researchers have tackled the question of how to create a workforce capable of delivering quality MNH care within an enabling environment for many years. Much attention has been given to interim strategies such as task-shifting [13], and the possible contributions of voluntary health cadres [14]. However, the problems inherent in creating, deploying, building, and maintaining a
127
quality professional workforce for MNH are only just gaining the prominence they deserve [15,16]. Often, supposedly skilled birth attendants do not receive the required midwifery training [16] or do not have the relevant competencies [17,18] to assist at birth. Fig. 3 shows the scale of this mismatch using data collected by the State of the World’s Midwifery 2014 report [16] from 73 countries with the highest burden of maternal and child mortality across the world. It shows the 10-fold difference between the human resources that are available and skilled to provide reproductive, maternal, and newborn health (RMNH) care based on a headcount of RMNH-related staff, and the amount of time spent by “truly skilled” birth attendants on these tasks. A lack of attention to the need for teamwork between skilled health professionals has had obvious implications for quality care, as not all women require the same type of professional assistance when giving birth. The recent State of the World’s Midwifery’s “Midwifery 2030 Vision” and the Lancet series on midwifery both stress the importance of collaborative and supportive teams of health workers where each professional’s scope of practice is respected and supported [16,19]. The skills and competencies of the workforce, as well as collaborative working between midwives, nurses, obstetricians, doctors, and other health staff must clearly underpin any strategy to improve quality care. Unfortunately, the forward planning needed to put a quality workforce into place is often not a focus for policy. The scale of the human resources challenge if the new SDGs are to be realized is significant and not widely understood. Africa in particular faces persistent health challenges and a rising population, and so demand for health workers continues to outstrip supply [20]. Despite some progress in closing the workforce gap, 39 African countries are deemed to have a critical health worker shortage [21]. Achieving global health and development goals therefore depends on strengthening health workforces in Africa. 3. An opportunity for accountability and action toward the new Sustainable Development Goals As the new Sustainable Development Goals (SDG) have now been agreed, we should seize the opportunity to build an accountability framework and its accompanying indicator set that is capable of delivering improved quality MNH care with a stronger workforce. Unless urgent action is taken to address the shortage and uneven distribution of health workers, none of these new goals can be met. It is predicted that by 2030, an additional 10 million health workers will need to be trained and deployed in low- and middle-income countries. That is
Fig. 2. New targets for newborn mortality. Reproduced with permission granted by Elsevier from Lawn et al. [26].
128
J. Campbell et al. / International Journal of Gynecology and Obstetrics 132 (2016) 126–129
Box 1 Desirable principles underlying a new accountability framework that promotes a quality-oriented health workforce. Looking forward, we need a contemporary narrative and an accountability framework that support a paradigm shift for quality across several dimensions of health workforce governance, development, and management, including a need to move: • Beyond targeting only numbers of health workers to recognizing that their accessibility, acceptability, and particularly quality and performance are equally important; • Away from training approaches focusing only on clinical competencies, embracing the transformative education agenda; • Toward recognizing that health workers are not just “inputs” for the health system, but individuals who require an enabling and supportive practice environment; • Away from a silo approach, and toward an integration of services in a continuum of reproductive, maternal, newborn, child, and adolescent care across phases of life and places of care-giving; • Beyond a rigidly hierarchical organization of healthcare teams, and toward a team-based approach that fosters inter-professional collaboration, making the most appropriate and effective use of specialists, general practitioners, midwives, nurses, mid-level and community-based health workers, according to their respective competencies and roles. Fig. 3. The midwifery workforce and the quality gap. The amount of time spent by cadres who are meant to carry out all skilled birth attendant tasks and have in theory practiced at least 25 supervised births are used as a proxy for “truly skilled” birth attendants. Reproduced with permission from UNFPA [16].
Adapted with permission granted by Elsevier from Cometto et al. [27]. mechanisms, stimulate action, contribute to collaboration between countries and global partners, and focus policy actions and investment decisions where they are most required. This will require—above all—good data collection mechanisms that build on existing and emerging sources. In order to include the SDG indicators on workforce, international and national data on human resources for health need to be augmented. Accountability at the level of individual countries can galvanize action on workforce issues but not without the most basic data for monitoring and decision making. Action must be taken to improve our workforce data or this most critical aspect of quality will be missing from the development databases. A fundamental initial step is to strengthen systems for collection and analysis of relevant health workforce data; this needs to go beyond routine information on availability of health workers, and should also include evidence on geographical accessibility, employment status, gender, wage dynamics, quality, and workforce performance. Quality of care, although determined by multiple factors, can only be improved if the number of skilled workers is scaled up. Preventing maternal and newborn deaths depends upon it.
why governments have tasked WHO to develop a new Global Strategy on Human Resources for Health: Workforce 2030, which brings together the latest evidence and best practices from across the globe. As partners coalesce around the new Every Woman, Every Child Global Strategy, we have an opportunity to ensure synergy between partners and policymakers by bringing this initiative into alignment with the emerging Global Strategy on Human Resources for Health, which will be considered by the 69th World Health Assembly in 2016 [22]. Success will involve concrete recommendations under a single comprehensive framework on actions at international and national levels to strengthen health workforce governance and management for better quality of care, following the principles summarized in Box 1. Equally as important, indicators and priorities on a quality health workforce need to be driven by strong accountability mechanisms at country level where changes are actually made. Building a strong accountability framework for a workforce that delivers MNH quality care requires that the human resource needs of all health subsectors be considered together—joining up MNH advocates with specialists from other areas of health. Priority-setting will also need to include countries at all levels of development. The health workforce agenda is of global relevance, as recent evidence shows that countries at all levels of socioeconomic development face health workforce challenges in accelerating progress toward attaining and sustaining universal health coverage [9]. Moreover, there is in fact a single global health labor market for qualified professionals (such as gynecologists and obstetricians, but also for midwives and nurses), as shown by the attention given to international health worker migration [23].
Jim Campbell is the Executive Director and Giorgio Cometto is a Technical Officer at the Global Health Workforce Alliance. Laura Sochas is a Technical Advisor and Zoë Matthews is former evidence lead on the Evidence for Action program.
4. Enabling action through measurable targets and data on human resources for health
References
The SDGs commit us to “increas(ing) substantially…the recruitment, development training and retention of the health workforce” [24]. A measurable target associated with this goal will enable accountability
Conflicts of interest
[1] United Nations. Saving Lives, Protecting Futures. Progress Report on the Global Strategy for Women’s and Children’s Health 2010−2015. New York: United Nations; 2015. http://www.everywomaneverychild.org/images/EWEC_Progress_ Report_FINAL_3.pdf.
J. Campbell et al. / International Journal of Gynecology and Obstetrics 132 (2015) 126–129 [2] van Lerberghe W, Matthews Z, Achadi E, Ancona C, Campbell J, Channon A, et al. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. Lancet 2014;384(9949):1215–25. [3] United Nations. The Millennium Development Goals Report 2015. New York: United Nations; 2015. [4] Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet 2010;375(9730):2009–23. [5] Powell-Jackson T, Morrison J, Tiwari S, Neupane BD, Costello AM. The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal. BMC Health Serv Res 2009;9:97. [6] Ekirapa-Kiracho E, Waiswa P, Rahman MH, Makumbi F, Kiwanuka N, Okui O, et al. Increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study. BMC Int Health Hum Rights 2011;11(Suppl. 1):S11. [7] Graham W, Bell J, Bullough C. Can skilled attendance at delivery reduce maternal mortality in developing countries? In: De Brouwere V, van Lerberghe W, editors. Safe Motherhood Strategies: A Review of the Evidence. Antwerp: ITG Press; 2001. p. 97–129. [8] Van den Broek N, Graham W. Quality of care for maternal and newborn health: the neglected agenda. BJOG 2009;116(Suppl. 1):18–21. [9] Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014;384(9948):1129–45. [10] Souza J, Gülmezoglu AM, Vogel J, Carroli G, Lumbiganon P, Qureshi Z, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet 2013;381(9879):1747–55. [11] Miller S, Cordero M, Coleman AL, Figueroa J, Brito-Anderson S, Dabagh R, et al. Quality of care in institutionalized deliveries: the paradox of the Dominican Republic. Int J Gynecol Obstet 2003;82(1):89–103. [12] Hulton L, Matthews Z, Bandali S, Izge A, Daroda R, Stones W. Accountability for quality of care: Monitoring all aspects of quality across a framework adapted for action. Int J Gynecol Obstet 2016. [13] World Health Organization. WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task-shifting (OPTIMIZEMNH). Geneva: WHO; 2012. http://apps.who.int/ iris/bitstream/10665/77764/1/9789241504843_eng.pdf. [14] Lewin SA, Dick J, Pond P, Zwarenstein M, Aja G, van Wyk B, et al. Lay health workers in primary and community healthcare. Cochrane Database Syst Rev 2005(1): CD004015.
129
[15] UNFPA. State of the World’s Midwifery 2011: Delivering Health, Saving Lives. New York: UNFPA; 2011. http://www.unfpa.org/publications/state-worlds-midwifery2011. [16] UNFPA. State of the World’s Midwifery 2014: A Universal Pathway. A Woman’s Right to Health. New York: United Nations Population Fund; 2014. http://www. unfpa.org/sowmy. [17] Harvey SA, Blandón YC, McCaw-Binns A, Sandino I, Urbina L, Rodríguez C, et al. Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward. Bull World Health Organ 2007;85(10):783–90. [18] Hussein J, Bell J, Nazzar A, Abbey M, Adjei A, Graham W. The skilled attendance index: proposal for a new measure of skilled attendance at delivery. Reprod Health Matters 2004;12(24):160–70. [19] ten Hoope-Bender P, de Bernis L, Campbell J, Downe S, Fauveau V, Fogstad H, et al. Improvement of maternal and newborn health through midwifery. Lancet 2014; 384(9949):1226–35. [20] Campbell J, Dussault G, Buchan J, Pozo-Martin F, Guerra Arias M, Leone C, et al. A universal truth: no health without a workforce. Geneva: Global Health Workforce Alliance and World Health Organization; 2013. http://www.who.int/workforcealliance/ knowledge/resources/GHWA_AUniversalTruthReport.pdf. [21] World Health Organization. Joining hands for health workforce improvements: Ghana hosts consultation on new global health workforce strategy. http://who.int/ hrh/news/2015/hrh-improvements_ghana-consult/en/. Published 2015. Accessed September 2, 2015. [22] World Health Organization. Follow-up of the Recife Political Declaration on Human Resources for Health: renewed commitments towards universal health coverage. WHA67.24. Published 2014. http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_ R24-en.pdf. Accessed July 24, 2014. [23] World Health Organization. WHO Global Code of Practice on the International Recruitment of Health Personnel. http://www.who.int/hrh/migration/code/code_en. pdf?ua=1. Published 2010. Accessed September 2, 2015. [24] United Nations. Report of the Open Working Group of the General Assembly on Sustainable Development Goals. http://www.un.org/ga/search/view_doc.asp?symbol= A/68/970. Published 2014. Accessed September 2, 2015. [25] USAID. Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action. Washington, DC: U.S. Agency for International Development; 2014. https:// www.usaid.gov/sites/default/files/documents/1864/MCHVision.pdf. [26] Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every Newborn: progress, priorities, and potential beyond survival. Lancet 2014;384(9938):189–205. [27] Cometto G, Boerma T, Campbell J, Dare L, Evans T. The Third Global Forum: framing the health workforce agenda for universal health coverage. Lancet 2013;1(6): e324–5.