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Community health workers and the midwifery workforce - 23_nov2014 - Giorgio Cometto
- 1. AMREF Health Africa International Conference Nairobi 25 November 2014 Dr Giorgio Cometto, Global Health Workforce Alliance World Health Organization Community health workers and midwifery workforce: reflections on evidence and future agenda
- 2. 2 | Human resources for health: global challenges, global opportunities Source: Campbell et al, GHWA and WHO, 2013
- 3. 3 | Community health workers: an opportunity for maternal and child health, HIV, TB … "Lay health workers provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care" Lewin et al, Cochrane Rev, 2010 "Community health workers …were found to be especially effective in promoting mother-performed strategies (skin to skin care and exclusive breastfeeding)." Gilmore and McAuliffe, BMC Public Health 2013 "Community health workers were reported to enhance the reach, uptake and quality of HIV services, as well as the dignity, quality of life and retention in care of people living with HIV. The presence of CHWs in clinics was reported to reduce waiting times, streamline patient flow and reduce the workload of health workers. Clinical outcomes appeared not to be compromised." Mwai et al J Int AIDS Soc 2013
- 4. 4 | … and more "Non-specialist health workers have some promising benefits in improving people's outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol-use disorders, and patient- and carer-outcomes for dementia" van Ginneken et al, Cochrane Rev, 2013 "Overall, the studies consistently identified positive outcomes associated with CHW-delivered interventions, including decreased asthma symptoms, daytime activity limitations, and emergency and urgent care use." Postma et al J Asthma 2013 "CHW programmes can have large impacts on the control of Buruli ulcer in sub-Saharan Africa." Vouking et al, Pan Afr Med J 2013
- 5. 5 | Midwifery scale-up could avert 83% of all maternal and neonatal deaths, stillbirths Source: Homer C, Friberg I et al, Lancet, 2014
- 6. 6 | Success in reducing maternal mortality hinges on facility births and midwifery scale-up Source: Van Lerberghe W, Matthews Z et al, Lancet, 2014
- 7. 7 | Midwifery-led services can have better outcomes than standard care models Source: Lassi Z, Cometto G et al, WHO Bulletin, 2013 Lower use of intra-partum regional anaesthesia and episiotomies in midwifery-led care compared to traditional physician-led care
- 8. 8 | Value for money of CHWs investments "Using country GDP per capita as the WHO reference threshold for cost- effectiveness, all three CHW programmes found to be cost-effective. Incremental cost per life year gained was estimated to vary between $82 and $3,396. ... the CHW-led approach has a high likelihood to be a cost-effective approach to delivery of some essential health interventions." McPake B, Edoka I et al, GHWA and WHO, 2014 (Health Systems Research Symposium abstract; forthcoming publication)
- 9. 9 | Value for money of midwifery investment 16-fold Return on investment in terms of lives saved and costs of Caesarean sections avoided through investments in midwifery education and deployment to community- based services. (State of the World’s Midwifery, 2014)
- 10. 10 | The next frontier: CHWs in health systems • Community preparedness • Regular and sustainable remuneration package • Opportunities for professional development • Ensure supplies/ equipment • Effective referral systems • Regular monitoring & supervision • Clear/ transparent selection system involving communities • Curriculum to include scientific knowledge on basic preventive and curative care • Adapt contents to health system needs • Include CHWs in HRH planning • Have a budget line / resource allocation Planning Production/ Education Deployment / retention Perfor- mance Source: Bhutta et al, GHWA, 2010
- 11. 11 | The next frontier (2)! Effective coverage of midwifery care workforce is AVAILABLE? workforce is ACCESSIBLE? workforce is ACCEPTABLE? workforce provides QUALITY CARE? AVAILABILITY ACCESIBILITY ACCEPTABILITY QUALITY • A midwife is available in or close to the community • As part of an integrated team of professionals, lay workers and community health services • Woman attends • A midwife is available • As and where needed • Financial protection ensures no barriers to access • Woman attends • A midwife is available • As and where needed • Providing respectful care • Woman attends • A midwife is available • As and where needed • Providing respectful care • Competent and enabled to provide quality care. CRUDE COVERAGE EFFECTIVE COVERAGE Source: SoWMy 2014
- 12. 12 | Global shifts in causes of DALYs (1990-2010) Source: IHME, 2013
- 13. 13 | Pregnancies in 73 SoWMy countries (1950- 2100) Source: SoWMy 2014
- 14. 14 | Remember the future! Consider long-term vision for CHW integration • CHWs often seen as short-term stop-gap measure • But increasing and evolving needs on the horizon, i.e. "0" targets, growing NCD burden, demand for quality • Fiscal space improvements will allow greater investment in skilled HRH • Role of CHWs to evolve over next decades: less diagnostic/ curative, more health promotion, chronic care management, treatment compliance • Plan for CHWs with the country's long-term needs and vision in mind • Envisage evolving role for CHWs in health systems • Tailor selection, education, career pathways accordingly
- 15. 15 | Remember the future (2)! Enable midwifery scale-up and practice Enabling policy environment Enabling practice environment -align job titles, roles and responsibilities -allow to practice within full scope of profession -strong linkages education/ employment -licensing/ re-licensing systems -improve salaries -incentive for rural deployment/ retention -access to effective referral -professional development opportunities
- 16. 16 | Further information Health Workforce Department, WHO & Global Health Workforce Alliance World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: ghwa@who.int http://www.who.int/workforcealliance/en/ http://unfpa.org/public/home/pid/16021 http://www.thelancet.com/series/midwifery
Editor's Notes
- Efforts to achieve the health targets of the UN Millennium Development Goals set in 2000 are thwarted in many countries by shortages of health staff, their often inequitable distribution, and gaps in their capacity, motivation and gaps in their capacity, motivation and performance. The ambitious targets under consideration for by the United Nations as part of the Sustainable Development Goals that will replace the MDGs will only be achieved if dramatic improvements are made to strengthen the health workforce. Low- and middle- income countries face the most severe challenges when in ensuring a sufficient, fit-for-purpose and fit-to-practice health workforce. But countries at all levels of socio-economic development face the challenge of how to sustain the human capital required to guarantee universal access and universal health coverage. High-income countries in particular are often over-reliant on migrant health workers from developing countries, and have to plan for the growing need of the population.
- We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled up in 78 countries classifi ed into three tertiles using the Human Development Index (HDI). We selected interventions in LiST to encompass the scope of midwifery practice, including prepregnancy, antenatal, labour, birth, and post-partum care, and family planning. Modest (10%), substantial (25%), or universal (95%) scale-up scenarios from present baseline levels were all found to reduce maternal deaths, stillbirths, and neonatal deaths by 2025 in all countries tested. With universal coverage of midwifery interventions for maternal and newborn health, excluding family planning, for the countries with the lowest HDI, 61% of all maternal, fetal, and neonatal deaths could be prevented. Family planning alone could prevent 57% of all deaths because of reduced fertility and fewer pregnancies. Midwifery with both family planning and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and neonatal deaths. The inclusion of specialist care in the scenarios resulted in an increased number of deaths being prevented, meaning that midwifery care has the greatest eff ect when provided within a functional health system with eff ective referral and transfer mechanisms to specialist care.
- This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of lowincome and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Eff orts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of fi nancial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.