Jim Campbell: Impact of Migration on Maternal & Newborn Health. February 2013

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Presented to the All Party Parliamentary Group on Population, Reproductive Health and Nutrition, Madrid, Spain on February 25, 2013.

A WHO Code of Practice on the international recruitment of health personnel exists since 2010, though the first reporting by Member States in 2013 is very poor. The issue of international migration is often the immediate reaction when discussing migration ("brain drain"). However, evidence points to the fact this is less of a problem than internal migration, which leaves communities, families and women without access to the necessary health personnel and health services.

This presentation explores these issues with respect to the midwifery workforce, and in particular midwives. It uses data from the State of the World's Midwifery 2011, and the H4+ High Burden Countries Initiative to highlight the concerns.

The evidence confirms that without due attention to the availability, accessibility, acceptability and quality of healthcare professionals and other MNH health workers, there is a lack of effective coverage for women.

Further information is available from www.integrare.es

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  • What a great slide deck!!! Especially the disaggregated data in three countries (Afghanistan and Tanzania included)

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  • Background to ICS Integrare:The Instituto de Cooperación Social Integrare (ICS Integrare) was first established in 2006 and became a registered research institute in early 2007.ICS Integrare works to reduce social inequalities and inequities that affect health, education and prosperity, with a particular emphasis on gender, marginalized populations and those living in poverty.The institute works with governments, UN agencies, bilateral and multilateral development partners, professional associations, academic institutes and non-governmental organisations, participating in many professional networks. It is a member organization of the Partnership for Maternal, Newborn and Child Health (PMNCH), the Global Health Workforce Alliance (GHWA) and an Implementing Partner of the UNFPA.Our focus areas are Reproductive, Maternal, Newborn and Child Health (RMNCH), Human Resources for Health (HRH), Health Systems Strengthening (HSS) and the interactions between these. Background to the speaker:Jim Campbell (Director, ICS Integrare) is an expert in Human Resources (HRH) and Health Systems Strengthening (HSS) with operational management and integration expertise resulting from over 15 years experience of technical assistance at the country, regional and global levels. Jim was formerly a Consultant Health Advisor (HRH) with the UK DFID and Senior Health Specialist with the Global Health Workforce Alliance (GHWA). He has extensive experience of working with partners from global health programmes, country governments and technical and financing agencies to deliver workforce development and capacity building with consequent attention to monitoring, evaluation and adaptation of implementation methods. I would like to extend my thanks to all of you for giving me the opportunity to come and present our work here today. My apologies for conducting the presentation in English: both English and Spanish language versions of all presentations and slides will be made available to you all for ease of understanding.
  • When we talk about “migration” of health personnel, this is what most people think of: the migration of health workers from low-income to high-income countries. This type of migration can present problems in both the countries of origin and the recipient countries. For example, it may mean that health workers who are originally trained in different curricula, and with differing qualifications and experience, are hired to work in OECD countries like Spain, as this cartoon implies. This may have consequences for the provision of culturally-appropriate health care, i.e. the Spanish population may perceive these health workers as different to those locally trained. But it may also cause terrible harm in the countries of origin. Low-income countries, already faced with devastating shortages of health workers, may lose even more of their capable doctors, nurses and midwives, after years of investment in their education and training, as these are lured by the prospects of higher salaries abroad, and the search of a better life for themselves and their families – the problem of “brain drain”. However, this is not the only sort of migration of health workers that takes place. Internal migration, in both low-income and high-income countries, from rural to urban areas is also a major factor. These internal migrations create a great problem of inequity, as rural areas are left without access to the necessary personnel and services. This presentation will discuss some of the consequences of internal migration in more depth.
  • In the past 3 years, there have been many international resolutions, global conferences, and other international events related to midwifery and the midwifery workforce. A few of these are highlighted in this timeline. This shows that there are global discourses surrounding maternal and newborn health, influenced by many technical and political factors. At the same time, the political economy at the country level is in turn influenced by the global architecture.Some of the significant resolutions, conferences and events include:The launch of the Every Woman Every Child (EWEC) movement by UN-Secretary General Ban Ki-moon during the United Nations Millennium Development Goals Summit in September 2010. This movement aims to save the lives of 16 million women and children by 2015.The launch of the Global Strategy for Women’s and Children’s Health – a concrete plan to improve women’s and children’s health and accelerate progress towards the health MDGs. The launch of the Commission on Information and Accountability for Women’s and Children’s Health in January 2011 – a high-level commission to improve global reporting, oversight and accountability.The establishment of an independent Expert Review Group (iERG) to review progress of EWEC and implementation of recommendations of the Commission on Information and Accountability.2011 World Health Assembly (WHA 64) passed resolution 64.6 on the strengthening of the health workforce and 64.7 on strengthening nursing and midwifery.2012 World Health Assembly (WHA 65) passed resolution on implementation of the recommendations of the Commission on Information and Accountability for Women's and Children's Health.Launch of the State of the World’s Midwifery Report (June 2011)London Summit on Family Planning (July 2012)UNFPA International Parliamentarian’s Conference on the Implementation of the IPCD Programme of Action in Istanbul. Rio +20 UN Conference on sustainable development.
  • Similarly, future events in 2013-14 will have a bearing on how maternal and newborn health is reflected in the post-2015 development agenda for health. For example, the Obama Administration is meeting today to review a new US-led initiative on reducing maternal and newborn mortality. These discussions are likely to result in a major new policy announcement later this year. The current development of the SOWMY 2014 report is scanning the global architecture to make sure it is relevant and added value to global and national issues when it is launched in June of next year. Now we’re going to look at the State of the World’s Midwifery Report 2011 and the issues resulting.
  • The State of the World’s Midwifery Report,launched in June 2011 at the Triennial Congress of the International Confederation of Midwives (Durban, South Africa) was developed in collaboration with more than 30 international agencies and organisations, including UNFPA, the International Confederation of Midwives and the World Health Organization. It provides the first comprehensive analysis of midwifery services, education, regulation, deployment and conditions of service in 58 countries where maternal and newborn mortality are highest. The launch was covered in your Parliamentary Group newsletter, number 22 (June 2011).The 58 countries profiled in the report represent 91% of the global burden of maternal mortality, 80% of the global burden of stillbirths, and 82% of the global burden of neonatal mortality – but only 58% of the world’s total births per year, and crucially, only 17% of the world’s health workforce.
  • The report focused on the contribution of midwives and midwifery to the continuum of MNCH. This graphic relates the competencies and scope of practice of a midwife in the continuum of care. An innovation of the report was the definition of a “newborn”. There is no global consensus on what is a ‘newborn’ and how newborn deaths should be measured. The SOWMY report suggested that a newborn should be considered as birth to 3 days, as this is the time when most newborn deaths occur.
  • Each of the country profiles in the report included a barometer of key indicators. This is the example of Bolivia. Bolivia is one of the poorest countries in South America, and suffers from a shortage of qualified human resources for maternal health, particularly in rural areas and among indigenous populations. Note that the figures presented on this page are nationwide– which can mask deep inequalities within the country. Contributing factors to this poor situation of maternal health include insufficient access to and availability of quality emergency obstetric carelow use of family planning services an inadequate referral system.Neonatal mortality, which is the current WHO metric for deaths from birth to 28 days, is nearly 1 in 2. 43% of all under 5 deaths are in the first month of life. It is most likely that these are actually in the first 3 days of life, but this is not measured by the WHO metric.
  • Although Bolivia has achieved high reductions in MMR since 1990 and is on track to achieve MDG, the MMR still stands at 180 per 100 000 live births is the highest in South America (for comparison, MMR in Spain is 6/100 000) . That is, a woman in Bolivia is 30 times more likely to die during pregnancy than a woman in Spain. Bolivia is experiencing heavy rural to urban migration, and indigenous and rural women are less likely to access health services. These graphsshow just how striking the inequalities are between urban and rural areas. In rural areas, less than half of women deliver at a public or private facility, while this figure is above 70% in urban areas. Similarly, although the overall figure for births attended by skilled health personnel is 66%, there are huge differences between the city and the countryside. Almost 90% of women who live in cities receive care from skilled health personnel during deliver (overwhelmingly doctors), while less than half of women living in rural areas receive skilled attendance. The government is taking steps to improve maternal health outcomes, particularly in rural areas. Some measures taken include:Offering free health care to pregnant women and children under the age of five. A conditional cash transfer programme (2008) to increase antenatal care and reduce malnutrition. An initiative to develop capacity of teachers and graduate a new cadre of obstetric nurses was started in 3 universities in 2008. New faculty have been trained and student enrolment from rural areas has been encouraged. The first intake of students commenced in 2010.Following steps that need to be taken:Official recognition and incorporation of the new cadre of obstetric nurses into the national health system.Continuing education and ensuring an adequate supply of commodities and equipment – the enabling environment that midwives require for their work.
  • The main conclusions of the SOWMY reportare: There is a triple gapof competencies, coverage and access. In most countries there are not enough fully-qualified midwives and others with midwifery competencies to manage the estimated number of pregnancies, births and complications. WHO estimates that 38 countries have severe shortages. A few countries will need more than a 10-fold increase in the number of midwives, with most needing to either double, triple or quadruple their midwifery workforce to improve quality and coverage. Second, coverage of emergency obstetric and newborn care facilities is low; and existing facilities are often insufficiently staffed and poorly equipped. This is most acute in rural and/or remote communities. Third, access issues from women’s perspectives are often not addressed.Education, regulation and association are not sufficiently focused on achieving quality of care. First, although there are promising education developments in some countries to graduate additional midwives proficient to practise all the essential competencies, the optimal standards are not being met. Curricula, faculty, educational resources and supervised exposure to clinical practice all need strengthening. Second, regulation and regulatory processes are currently insufficient to promote the professional autonomy of a midwife and to fulfil government obligations to protect the public. In almost every country, registration and licensing of the midwifery workforce, including criteria for renewing a licence to practise, require improvement.Third, there is a positive trend across countries to establish and develop professional associations to represent midwives, but many are in their infancy and some are fragile. These associations need additional support and collaboration from national, regional and international partners.There is a lack of policy coherence and access to the necessary strategic intelligence. National policies addressing maternal and newborn health services too often do not address the central importance of the midwifery workforce nor the criticalneed to improve quality of care. Most countries are not able to accurately monitor the number of practising midwives in either the public or the private sector, or to assess the extent to which the midwifery workforce is able to provide quality interventions in response to population needs. This limits the availability of strategic intelligence to inform policy improvements. Similarly, while mechanisms to review quality of care are emerging, more needs to be done on its measurement and on evidence for action. The issue is not that women are hard to reach, rather, the issue is the system, the governance, the political will to address this and tackle the failed to reach.
  • Addressing the failed to reach is the most important challenge. Ban Ki-moon made it clear in the preface to our State of the World’s Midwifery Report: this requires bold action. As parliamentarians, you have a responsibility to support and lead these bold steps.
  • I have discussed the work that we have done up until 2011 with the State of the World’s Midwifery. I am now going to talk about the work that we have done since 2011: the High Burden Countries Initiative (HBCI), supported by the Health 4+ agencies, which expands on the research that we conducted for the State of the World’s Midwifery and looks at the issues within a country, including internal migration.
  • The Health 4+ (H4+) agencies (UNAIDS, UNFPA, UNICEF, UN Women, WHO and the World Bank) are working together to support the Every Woman Every Child Campaign. One of the ways in which they are doing this is through the H4+ High Burden Countries Initiative (HBCI) that is supporting detailed assessments of midwifery in 8 countries which represent nearly 60% of global maternal and newborn deaths. National assessment reports are currently being finalized for Afghanistan, Bangladesh, Ethiopia and Tanzania (expected publication in April), and preliminary work has started on the assessments in DRC, India, Mozambique and Nigeria.The National Assessments follow on from the data collected for the State of the World’s Midwifery 2011. They look at gaps in service availability, quality and accessibility. The research aims to support national governments in developing and budgeting strategies for scaling up the midwifery workforce and improving maternal and child health outcomes.  
  • To understand need, we looked at disaggregated country data, not national figures. The maps here show differences within the countries. This is to ensure that the health system response is focused on equity, and responsive to population needs in remote, rural and urban areas. We want to ensure that your place of birth does not determine your right to life. Data is extracted from the country demographic and health surveys (DHS). We developed an algorithm to convert the data to age-specific fertility rates by district. This data was related to population data at 1km2 (available from afri/pop and asia/pop using advanced satellite mapping technologies) to produce the expected pregnancies per district per year. It is important to note that data is collected in terms of pregnancies per year, not births per year. This provides a far more sensitive estimate of the demand on health systems, health services and health workers, than births.   
  • To understand supply we followed recognized methods to conduct a labour market analysis, as developed by the World Bank and WHO.The research is interested in the pipeline from high school to employment in the public and/or private sectors. We consider the barriers and bottlenecks to whether investments in education will result in active participation in the health labour market. We consider the availability (numbers), accessibility (deployment), acceptability (to women and their families) and the quality of the workforce.  The approach reveals interesting results:In some countries, as many as 1 in 2 graduates are not working within 24 months of leaving their education programme.In one country, we found that many of the midwifery graduates are male, yet they are not acceptable in the local culture to practices as midwives.In another country, we found that once trained to be a midwife, there was increasing pressure to marry. The woman was now considered to be very well-educated and therefore attractive in the practice of arranged marriages. Once married, the new mother-in-law would prevent the midwife from working.
  • This slide, a Lorenz Curve, is more commonly seen in economics papers tan in discussions about Maternal and Newborn Health. The basic principle is that it describes the distribution of something, normally wealth, in relation to the population. The 45-degree line running from the bottom left to the top right is the line of equity. Anything below the 45-degree line reports inequity.  The science is increasingly used to explore the distribution of the workforce within a country. The World Bank has adopted this in much of their work and the Global Health Workforce Alliance is supporting this. It helps to understand the distribution between urban and rural areas and to identify where there are shortages. In this respect, it helps us to understand whether internal migration is an issue. For instance, in this country 70% of the obstetrics workforce is providing services to only 30% of the urban population. The rural population has very little access to specialists in emergency obstetric care.
  • The Tanahashi Framework was first published in the Bulletin of the World Health Organization in 1978. It was part of broader health architecture at that time to support ‘Health for All” by the year 2000. It seeks to answer whether health services provide effective coverage by looking at the availability, accessibility, acceptability, utilization and quality of care. The same logic is used in the UNICEF/World Bank/WHO tool on Marginal Budgeting for Bottlenecks.  We have adapted this for Human Resources for Health and the Midwifery Workforce Assessments. This also allows us to look at equity and whether health workers are available in both urban and rural areas but also to discuss what is the real quality of care provided to women and newborns.  
  • These graphics provide a visual account of the current status of effective coverage in Afghanistan. The first graphic serves to explain the model employed. This model is an adaptation of a) the three dimensions of universal health coverage; b) the availability, accessibility, acceptability, and quality (AAAQ) components of the right to health, and; c) the Tanahashi framework from the era of Health for All. In this model the X-axis depicts the percentage of the population that is covered by health services. The Z-axis represents the services covered, in this case using the PMNCH Essential Interventions as a guide for minimum required services. Finally the Y-axis is illustrative of direct costs: showing the percentage of MNH services that are covered by government, or through pre-payment and taxation. The outer box represents the ideal of universal coverage in which 100% of population is covered by services that include all of the Essential Interventions and without additional charge.These graphics provide a visual account of the current status of effective coverage in Afghanistan. The first graphic on the top left serves to explain the model employed. This model is an adaptation of a) the three dimensions of universal health coverage; b) the availability, accessibility, acceptability, and quality (AAAQ) components of the right to health, and; c) the Tanahashi framework from the era of Health for All. In this model the X-axis depicts the percentage of the population that is covered by health services. The Z-axis represents the benefit package covered, in this case using the PMNCH Essential Interventions as a guide for minimum required services. Finally the Y-axis is illustrative of direct costs: showing the percentage of MNH services that are covered by government, or through pre-payment and taxation. The outer box represents the ideal of universal coverage in which 100% of population is covered by services that include all of the Essential Interventions and without additional charge. The inner cube represents the human resources for health and the dimensions of AAAQ.  The second graphic on the bottom right is specific to Afghanistan. Data from 2010 shows less than 35% (34.3%) SBA coverage in Afghanistan; therefore the inner box only covers 35% of the X-axis. As the BPHS/EPHS system is quite coherent with the guidelines provided in the PMNCH Essential Interventions, the Z-axis is considered to be at 90%. Similarly, policy dictates that all MNH services should be free of charge and therefore the Y-axis is illustrated at 100% in this diagram. However evidence indicates that there are significant gaps between the reality and policy goals regarding both services covered and hidden/unregulated fees. The actual effective coverage is understood to be even less than the coverage illustrated by the dotted block in this graphic.Within the dotted block adjustments have been made based on the expert opinion obtained through an adapted Tanahashi exercise completed for both urban and rural settings in Afghanistan. After weighting for accurate urban-rural proportions, the mean scores were then calculated. The final effective coverage is slightly less than15 % effective SBA coverage, falling short of the already low reported rate of 34.3% skilled birth attendance for the women of Afghanistan.Data from 2010 shows less than 35% (34.3%) SBA coverage in Afghanistan; therefore the inner box only covers 35% of the X-axis. As the BPHS/EPHS system is quite coherent with the guidelines provided in the PMNCH Essential Interventions, the Z-axis is considered to be at 90%. Similarly, policy dictates that all MNH services should be free charge and therefore the Y-axis is illustrated at 100% in this diagram. However evidence indicates that there are significant gaps between the reality and policy goals regarding both services covered and hidden/unregulated fees. The actual effective coverage is understood to be even less than the coverage illustrated by the dotted block in this graphic.Within the dotted block adjustments have been made based on the expert opinion obtained through an adapted Tanahashi exercise completed for both urban and rural settings in Afghanistan. After weighting for accurate urban-rural proportions, the mean scores were then calculated. The final effective coverage is left at only 5.2% effective SBA coverage, falling far short of the already low reported rate of 34.3% skilled birth attendance for the women of Afghanistan.
  • Thankyouforyour time and attention!
  • Jim Campbell: Impact of Migration on Maternal & Newborn Health. February 2013

    1. 1. Impact of migration onaccess to maternal andnewborn health servicesV Parliamentary Meeting on Global Health:The migration of the health workforce andits impact on global healthMadrid26 February, 2013Jim CampbellDirector, ICS Integrare, Barcelona, Spainenquiries@integrare.es
    2. 2. Impact of migration on access to maternal and newborn health services. Source: Ferreres, June 2008
    3. 3. Impact of migration on access to maternal and newborn health services. 2. A historical look: HRH for MNH 2010 - 2012 2010 2011 2012 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D `` `` ` ` ` ` ` ` `` ` ` `` `` ` ` ` ` ` ` `` ` ` `` Women Deliver `` EWEC ` ` ` SOWMY iERG ` ` ICPD`Global `` ` ` Midwifery launch 2011 CSO Symposium consultation Global Strategy for Women’s and WHA 64 HBCI Children’s Health WHA 65 UNFPA International Commission on Information and Parliamentarians Accountability for Women’s and Conference Children’s Health Rio+20 UN High-Level Panel Post-2015 London Summit on Family Planning
    4. 4. Impact of migration on access to maternal and newborn health services. 3. A forward look: HRH for MNH 2013 - 2014 2013 2014 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ` ` ` `GMHC USAID ` GBC Women Lancet SOWP HRH Prince Mahidol ICM EWEC 50X2035 Health Deliver EWEC Congress Forum High-level ICPD Human meeting on Rights MDGs STATE OF THE WORLD’s MIDWIFERY $ Mobilisation CONCEPT DEVELOPMENT CONCEPT FINAL (En) ENDORSED For copy layout, LAUNCH DATA translation etc COLLECTION 75 Countdown DRAFT REPORT
    5. 5. Impact of migration on access to maternal and newborn health services. 4. The State of the World’s Midwifery Report 2011. High Burden Countries
    6. 6. Impact of migration on access to maternal and newborn health services. 4. The State of the World’s Midwifery Report 2011.
    7. 7. Impact of migration on access to maternal and newborn health services. 4. The State of the World’s Midwifery Report 2011. Profile on Bolivia.
    8. 8. Impact of migration on access to maternal and newborn health services. 4. The State of the World’s Midwifery Report 2011. Profile on Bolivia.
    9. 9. Impact of migration on access to maternal and newborn health services.4. The State of the World’s Midwifery Report 2011. Summary messages (with caveats) 1. Practising workforce (and quality) not known 2. Inadequate numbers – inequitable coverage 3. ‘Triple gap’ – competencies, coverage, access 4. Education, regulation, professional association – weak 5. Policy coherence – missing “Failed to reach” NOT “Hard to reach”
    10. 10. Impact of migration on access to maternal and newborn health services. “Ensuring that every woman and her newborn have access to quality midwifery services demands that we take bold steps” Ban Ki-moon, Secretary-General of the United Nations
    11. 11. Impact of migration on access to maternal and newborn health services. 2. A historical look: HRH for MNH 2010 - 2012 2010 2011 2012 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D `` `` ` ` ` ` ` ` `` ` ` `` `` ` ` ` ` ` ` `` ` ` `` Women Deliver `` EWEC ` ` ` SOWMY iERG ` ` ICPD`Global `` ` ` Midwifery launch 2011 CSO Symposium consultation Global Strategy for Women’s and WHA 64 HBCI Children’s Health WHA 65 UNFPA International Commission on Information and Parliamentarians Accountability for Women’s and Conference Children’s Health Rio+20 UN High-Level Panel Post-2015 London Summit on Family Planning
    12. 12. Impact of migration on access to maternal and newborn health services.5. High Burden Countries Initiative: Midwifery Workforce Assessments Afghanistan Bangladesh Completed: 2012-2013 Tanzania Ethiopia Mozambique India In progress: 2013 onwards DR Congo Nigeria
    13. 13. Impact of migration on access to maternal and newborn health services.5. Assessing need – pregnancies per year Afghanistan Ethiopia “Your place of birth should “If you miss the not determine poor, you miss your right to the point” Tanzania life”
    14. 14. Impact of migration on access to maternal and newborn health services.5. Assessing supply: Health labour market analysis Public Private Other Health sector ‘supply’ Exits Employed Unemployed ‘participation’ ‘potential Qualified healthcare workers supply’ Healthcare education and training High School graduates (male/female) Source: adapted from Vujicic and Zurn, 2006
    15. 15. Impact of migration on access to maternal and newborn health services.5. Assessing supply: urban/rural distribution - equitable?
    16. 16. Impact of migration on access to maternal and newborn health services.5. Modelling future supply: if we use Tanahashi? Service Delivery Goal Target population who do not contact Effective Coverage services Process of service provision People who receive effective care Contact Coverage People who use the service Acceptability Coverage People willing to use the service Accessibility Coverage People who can use service Availability Coverage People for whom service is available Target Population
    17. 17. Impact of migration on access to maternal and newborn health services.5. Evaluating effective coverage in Afghanistan
    18. 18. Impact of migration on access to maternal and newborn health services.For further information: Please contact Jim Campbell ICS Integrare Barcelona, Spain Twitter: integrare Website: www.integrare.es

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