N/A

1. Community Health Nursing and
improving access and equity: A global
perspective
 10th Conference of the Global Network of WHO
 Collaborating Centres, 23-25 July, 2014
 Coimbra, Portugal
Annette Mwansa Nkowane, RN, RM, Bsc, MA
Technical Officer, Health Workforce Department
Health Systems and Innovations, WHO, Geneva, Switzerland

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Presentation
Community Health Nursing
The context
WHO Multicounty Study
Opportunities
Conclusion

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Community health nursing
“A field of nursing that combines the skills of nursing, public health and some phases of social assistance and functions as part of the total public health programme for the promotion of health, improvement of the conditions in the social and environment, rehabilitation of illness and disability"
World Health organization, Community Health nursing, 1974. Report of the WHO Expert Committee. WHO Technical Report Series 558, Geneva Switzerland.

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The context (1) Unmet human recources for health needs
A global chronic shortage of well-trained health workers
Countries with the greatest public health threats are more affected.
57 countries facing crippling health workforce shortage, mostly in sub-Saharan Africa but also including Bangladesh, India and Indonesia.
Globally, nurses and midwives are recognized as the central pillar of health care systems
Not sufficient numbers are trained or retained
Nursing and midwifery workforce aging with a decline in younger women choosing nursing as a career

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The context (2) Density of nursing and midwifery personnel, latest available year Global Health Workforce Statistics database, 2013 update
(http://who.int/hrh/statistics/hwfstats/en/index.html)

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The context (3) Global Health Workforce Statistics database, 2013 update
(http://who.int/hrh/statistics/hwfstats/en/index.html)

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The context (4)
Economic burden of NCDs and mental disorders
GLOBALLY
0
5
10
15
20
25
30
35
40
45
50
Low income Lower-middle
income
Upper-middle
income
High income World
Foregone economic output (US$ trillion, 2011-2030)
Mental, neurological and
substance use disorders
4 major NCDs (CVD, diabetes,
cancer, respiratory disorders)
(Source: WEF, 2011 – The Global Economic burden of NCDs)

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The context (5) Years lived with disability

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The context (6) Commuicable Diseases
AIDS, TB and Malaria are still global public health threats
1. HIV global achievements notable but:
- Many children still affected with HIV
- Access to testing and treatment still a challenge
- Key population groups missing out on recent progress
2. Of the 9 million who develop TB each year, 1/3 not reached with diagnosis and treatment
3. Malaria still endemic in 99 countries causing estimated 219 million cases and 660,000 deaths
Other communicable diseases e.g. Ebola virus diseases (EVD) devastating communities

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WHO Multi-Country Study
Period
•Between 2010 and 2012
Purpose
•To determine the existing scope of practice of Community Health Nursing in selected countries experiencing a critical shortage of human resources for health
Countries
•18 from 4 WHO regions: AFRO (5), SEARO (6), WPRO (4), & AMRO (3)
Participants
•Directorates of Nursing (13)
•Nursing Regulatory bodies (10)
•Nursing/midwifery Training institutions (44)
•Nurses/Midwifery Associations (11)
•Practicing Community Health Nurses (428)

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Health Systems and Services
All countries had Primary Health Care (PHC) as strategy for health care service delivery
17 had a specific National strategy for Human Resources for Health – 8 (47%) were developed after 2005
11 (64%) had a specific national strategy for strengthening Nursing and Midwifery services
15 (83%) had Community Health Nursing as a recognized profession

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Policy and Practice of Community Health Nursing
All countries had institutions for responsible for policy, training, regulation, accreditation and monitoring and evaluation of nursing services
The roles and functions of the institutions differed between the countries
80% (12/15) of the Nursing Directorates were responsible for Policy formulation and review
86% (13/15) of the countries CHN was recognized profession had a clear mechanism for monitoring workforce performance
Only 9 (50%) of the countries had specific retention packages (incentives) for nurses working in hardship areas
Types of incentives:
Incentives considered effective frequently named by policy makers were:
personal/professional support (50%);
educational support (25%)
financial incentives (19%)
Educational/staff development incentives commonly offered by the 8 countries included :
Continuing education (32%);
Training (21%),
Scholarships (5%)

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Education, Training and Career Development (1)
Of the 15 professional regulatory bodies participating 12 (80%) were involved in formulation/review of educational syllabus for nurses and midwives.
CHN offered as a post-basic qualification in 7 (38%) countries f the, in 8(44%) an entry level exam is a requirement for admission to the training programme.
Nine (60%) of the regulatory bodies regulated the scope of CHN.
11 (73%) indicated there was a career structure for the Community Health Nursing profession

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Education, Training and Career Development (2)
33%
20%
27%
20%
Level of qualification for CHN
Diploma (5)
University Degree (3)
Diploma & University Degree (4)
Other (3)

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Education, Training and Career Development (3)
28%
28%
17%
14%
13%
Roles the training of Community Health Nurses are prepared for
Service & health care delivery
Counseling, consultation & education
Leadership/administration/Management
Coordination/Supervision/advocacy
Others

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Community Health Nursing Practice (1)
Background educational status
–76% received formal training in Community Health Nursing
–In 51% of them, the training was more than 24 months
–Only 15% indicated their training involved training with other health professionals (primarily medical doctors and other nurses)
–In 91%, the practicum period was at least 12 months duration
Deployment and Practice after qualifying
– 56% were to health centres or PHC clinics and 24% to hospitals
–68% currently work with other health professionals
–Commonest tasks performed by the CHNs are
•Maternal and child health (30%)
•General health care provision (23%)
•Administration (16%)
•Health education (10%)

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Community Health Nursing Practice (2)
Performance of tasks by CHNs
– 35% reported they performed tasks that they were not trained for
–Areas of work most named where CHNs felt they could contribute more were
•Community Health Nursing (24%)
•Expanding community level activities for health disease prevention (20%)
•Quality care provision (10%)
•Research (9%)

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Community Health Nursing Practice Incentives
Conditions of service of CHNs
– Incentives were received by 21% of CHNs
–Commonest named were allowances (7%) and continuing education and professional development (6%)
–Almost 96% indicated there were clear mechanisms for evaluation of their performance.
–90% had an assessment of their performance in the previous two years
0
5
10
15
20
25
30
35
40
45
Percentage of Responses
Incentives Considered to be Effective

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Summary of interventions
Health Promotion
- education
-counseling
- support tools
Disease Prevention
- Risk Assessment
- Screening
- Treatment
Disease Management
- case management
- care coordination
- care provision, including patient monitoring, treatment, counseling, teaching, etc.
Key Roles at all times
- policy, planning, evaluation, advocacy
Key role in supporting development and implementation of effective national responses in accordance with the national contexts, needs and priorities

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Opportunities (1)
In the 70's Global community made a commitment to Primary Health Care
Commitment emphasized Equity, Community participation, Health Promotion, Intersectoral approaches, appropriate technology, effectiveness and accessibility
This commitment remains today as key in management of human resources of public health nurses
Public health nurses can effectively contribute to universal health coverage (UHC)
UHC is defined as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

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Opportunities (2)
PHC renewal
 A sense of
direction for
fragmented health
systems
 Dealing with
current and future
challenges to
health

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Opportunities (3) WHA Resolutions on HRH
•International migration of health personnel: a challenge for health systems in developing countries (WHA57.19)
2004
•Rapid scaling-up of health workforce production (WHA59.23)
•Strengthening nursing and midwifery (WHA59.27)
2006
•Primary health care, including health system strengthening (WHA62.12)
2009
•WHO Global Code of Practice on the International Recruitment of Health Personnel (WHA63.16)
2010
•Strengthening the health workforce (WHA64.6)
•Strengthening nursing and midwifery (WHA 64.7)
2011
•Transforming health workforce education in support of universal health coverage (WHA66.23)
2013

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Opportunities (4) Strengthening nursing and midwifery (WHA 64.7)
"….implementing strategies for enhancement of interprofessional education and collaborative practice including community health nursing services as part of people-centred care; including nurses and midwives in the development and planning of human resource……."

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Opportunities (5) Cross-cutting principles
1.Universal health coverage
2.Human rights
3.Evidence-based practice
4.Life course approach
5.Multisectoral approach
6.Empowerment of persons with mental disorders and psychosocial disabilities

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Conclusion (1)
Community Health Nursing contributes to health services in the community. There are gaps and shortcomings identified in the study to be addressed and strengthened:
Their educational preparations, though varied between countries surveyed, but need to be strengthened
Enhance Key roles including planning of health activities, management of other health professionals and coordination and planning with other partners
CHNs practice in a variety of settings, appropriate policies , based on professional needs assessments are critical
Health care training has traditionally tended to be largely biomedical with emphasis on diagnosis and treatment of acute problems
Refocus to embrace continuum of care –health promotion, disease prevention, acute care, palliative and rehabilitative care

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Conclusion (2)
Nurses are the main professional component of the "Frontline staff in most health systems and their contribution is recognized as essential for universal health coverage
Conditions of service must be conducive enough to retain CHNs in the practice
Need for opportunities to develop professionally, gain autonomy and participate in decision making, fair rewards to attract and retain any category of nurses

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THANK YOU