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Health Worker Migration Global Dialogue


8-16 November 2010
http://my.ibpinitiative.org/whoguidance/Optimize4MNH

The purpose of this discussion was to inform the WHO guidance development process by exploring issues related to enhancing the effectiveness of different cadres of health workers through evidence-based practices to improve maternal and newborn health (MNH) care.

Discussion Statistics


Number of participants: 692
Number of participants' countries: 91
Number of contributions: 187
% of contributions from developing countries: 76%
Number of countries contributing: 33 countries

Contributing countries: Australia, Bangladesh, Cambodia, Cameroon, Canada, China, Cote d'Ivoire, DRC, Ethiopia, Germany, Ghana, Grenada, India, Indonesia, Iran, Kazakhstan, Kenya, Malawi, Morocco, Nepal, Nigeria, Norway, Pakistan, Philippines, Puerto Rico, Sri Lanka, Sweden, Switzerland, Tanzania, Uganda, United Kingdom, United States, Zambia.



Purpose and Objectives

Purpose:
Objectives:                                                                      
                                 
Day 1.  The role of health care providers 
Question

  • What practices or tasks can be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?

Emerging themes and issues:
  • With appropriate referral support, almost all tasks and procedures related to maternal and newborn care can be performed by skilled providers, such as midwives, nurses, and clinical officers (non-MD's). They should be trained to recognize conditions that are beyond their (and primary care) level and be supported to refer or consult in a speedy time frame so that more complicated patients that require the advanced knowledge and skills of MD's, accessible 24/7 to primary care providers-
  • Non medical staff should and can learn to carry out emergency obstetric care such as CS and hysterectomy for ruptured uterus. They need to have training and mentoring. Good evidence to support safety and good staff retention in rural areas.
  • The scope of tasks of a midwife according to ICM and practices which are expected of an average midwife anywhere in the world. Although the prescribed tasks fall perfectly within the range of primary care, there are situations where a midwife working in a remote area (without prompt referral link) is the individual with the highest professional authority to intervene when complication arises. This is the typical picture in many low and middle income countries where the bulk many times stops with the midwives and something has to be done. It is also important to view this message within a global context of midwife training which is likely to vary from country to country. Besides, regulatory interventions by professional bodies often differ between countries and some countries put a limit on how far a midwife could go. Promotional and preventive interventions (essentially primary care issues) readily fall within the jurisdiction of midwives but with the background of "optimizing" or expanding the roles of health workers, it would be nice to know what other roles that is outside their normal confines can they undertake. For instance, can a midwife perform a caesarean section; external cephalic version; administer magnesium sulfate for eclampsia where there is no doctor?
  • A non-hierarchical approach to caring for women makes more sense than looking at different providers as being on different levels particularly in settings where specialists are few. A Cochrane review which included 11 trials (with 12,276 women) comparing midwife-led model of care to medical- or shared-care model showed that midwife-led care is associated with reduction in use of analgesia, instrumental delivery and episiotomies and fetal loss less than 24 weeks but similar rates of caesarean section and overall fetal + neonatal death as other models of care. The result of this review has lead to the recommendation of women with no known medical complications to be offered midwife-led care. While this may be of significant benefits to reducing maternal and newborn mortality considering the density of midwives to obstetricians, it is unlikely that the finding of the review would be applicable to low and middle income settings that carry the highest burden of maternal and newborn death as majority of the trials were conducted in the public health systems in Australia, Canada, New Zealand and the United Kingdom. It is interesting to note that while women in high income countries have the choice of selecting between models of healthcare delivery; their counterparts in resource constrained settings have midwives as, by default, their primary providers of care during childbearing. The curriculum of midwifery training in developed countries where similar results were obtained between various models of care would need to be compared to those in developing countries to appreciate what could be done in this direction.
  • The importance of health workers being part of the community is reiterated in a recent WHO publication on Increasing Access to Health Workers in Remote and Rural Areas through Improved Retention.
  • Promotional and preventive interventions are within the scope of routine tasks of primary care providers. Within the context of expanding health workers roles, it would be nice to know which of these tasks can be delegated to those for which they were not primarily intended.
 
                                                                 
                                                       
Day 2. The role of health care providers 
Questions

  • In view of the global health workforce crisis, what could different cadres of health workers undertake that is outside their routine scope of work in order to reduce maternal and newborn mortality and morbidity?
  • For example, can we recommend midwives to perform external cephalic version, instrumental vaginal delivery and caesarean section? Lay Health Workers for labour companionship? Can we recommend non-clinician physicians (or clinical officers) to perform caesarean section, hysterectomy for ruptured uterus etc? At the PHC level, can midwives/nurses administer anticonvulsants? Uterotonics?

Emerging themes and issues:

  • Today’s contributions continued discussing the role for health care providers other than medical doctors in reduction of maternal and newborn mortality and morbidity. This discussion focused more specifically on the roles health care workers could take that is outside their traditional roles.
  • There was a considerable amount of discussion regarding scope of practice and standardization of training.
  • The skilled attendant will often be the only qualified and accredited health care worker during pregnancy, childbirth and the immediate postnatal period. TBAs, nurses to specialist physicians will contribute but will not have none of these will have either the extensive competence to perform. He says that WHO, ICM and FIGO hope to highlight the significance of the function of skilled attendants within the health care system for saving the lives of mothers and newborns.
  • Lay counselors and community-based volunteers are often considered to be a temporary measure, without any longer-term perspective due to lack of payment or incentives.
  • Recently the Ministry of Health in India approved introducing a mid-level provider to provide primary health care to rural areas. Unfortunately, the Indian Medical Association has launched a massive protest and lobbying to stall this programme.
  • Health care workers could provide active management of 3rd stage of labour for PPH prevention and timely initial care including uterotonics such as Misoprostol. Procedures like MVA may occasionally be allowed nurse/midwives who have been duly trained and who have shown proficiency. However, constant monitoring and evaluation is a necessity and specialist/ OB must oversee those activities.
                                                                         
                                                       
Day 3.   The range of tasks
Questions

  • In what ways can lay health workers contribute to improving antenatal care for women? How should this cadre be involved in newborn care?
  • Are there examples of innovative programmes in which the range of tasks undertaken by lay health workers have been expanded or that utilize innovative technologies or organizational models to improve the provision of care by lay health workers?
  • Should teams of lay and professional providers be established in primary care facilities?
  • Should nurses be responsible for supervising the work of community health workers?
  • How should decisions be made about the range of tasks that community health workers undertake?

Emerging themes and issues:
 
  • Some contributors shared the concern that the use of lay health workers as a temporary measure may become permanent, even if the lay workers do not have adequate training. The roles and tasks that are undertaken by different cadres, including lay health workers, need to be both evidence-based and appropriate to the local setting. In some settings, it may be most appropriate for lay health workers to focus on prevention and promotion while in other settings, particularly where access to care delivered by professionals is poor, lay health workers may take on a wider range of tasks.
  • There is a role for lay health workers in medical supply management. There have been promising improvements in medical supply availability in several Pacific Island Countries following specific training in these areas for nurses and other workers (such as VHWs) who deal directly with patients. This approach is being trialed currently in several more countries in the region.
  • It is important to not look at lay cadres in isolation but rather consider their roles in relation to the wider health team, the health system and society more broadly.
  • Lay health workers should have a role in both prevention and education.
  • Roles and responsibilities for lay health workers should be clarified at the national level. Mohammad adds that adherence to these guidelines must be monitored.
  • Some roles traditionally reserved for doctors could be cascaded down to nurses and some roles of nurses could be cascaded down to lay health workers if proper education and mandatory monitoring of skills is undertaken.
  • Several contributors highlighted the need for guidelines or manuals that outline the tasks and roles of lay health workers.
  • A number of studies have identified poor links between lay health worker programmes and the wider health system as an important barrier to maximizing the health gains that these programmes might offer.
 
                                                                 
                                                       
Day 4.Role of lay health providers
Questions

  • What wider social roles, such as promoting female empowerment, should lay health workers take on in communities?
  • What approaches that have been used in different settings to motivate and retain lay health workers, to improve the quality of the services they deliver and to promote the delivery of high priority services for maternal and newborn health?
  • Contributors have highlighted the need for guidelines or manuals that outline the tasks and roles of lay health workers. It would be useful to hear more about existing guidelines of this sort, including how they are used and the extent to which they are evidence-based. Given the wide variation across settings in the tasks that lay providers take on, what functions might guidelines at the international level on optimizing tasks and roles have?
  • What strategies have been used to improve collaboration between lay providers and professionals, particularly nurses working in primary care? How has the allocation of roles and tasks between different cadres been negotiated or established in different settings?


Emerging themes and issues:

  • Lay or community health workers (LHWs) are being used across a wide range of settings and undertake varied tasks to improve maternal and neonatal health, depending on local needs as well as local views and regulations regarding their scope of practice. The discussion has helped to outline this range of tasks and this will be very valuable for the Optimize4MNH initiative
  • There are differing opinions regarding the roles and tasks that should be undertaken by LHWs. As I noted yesterday, in some settings it may be most appropriate for LHWs to focus on prevention and promotion while in other settings, particularly where access to care delivered by professionals is poor, lay health workers may take on a wider range of tasks. In general, the tasks undertaken by different cadres, including lay health workers, need to be both evidence-based and appropriate to the local setting
  • A number of important factors contributing to effective LHW programmes were raised, including appropriate initial and ongoing training; evidence-based guidelines and / or manuals to support practice in the field; supportive supervision from other cadres at primary care level; regular supplies of drugs and equipment; a robust referral network; and appropriate forms of incentivisation, to name a few. Overall the key message seemed to be that LHW programmes needed to be embedded in both the wider health system and the local community, and could often act as a bridge between the two
  • There was considerable discussion on how to motivate and retain trained LHWs. The range of incentives that should be used within such programmes (including acknowledgement within their communities, stipends or wages) is also the subject of ongoing debate in the academic and policy literature. In developing strategies to motivate and retain lay providers, it is probably important to ensure that the context-specific expectations of this group, as well as of programme managers, policy makers and communities, are taken into consideration
  • Contributors described a range of innovative strategies for utilizing the capacity of LHWs. For example, in improving medical supply management; delivering long term contraception; providing rehabilitation services at community level; and delivering birth-dose Hep B vaccination using Uniject devices. I feel that we need better ways of sharing these experiences of innovation – the last two days of discussion are a small step in that direction
  • LHWs are not a solution to weak health systems and a number of contributors noted that such programmes may function poorly, and may not be sustainable, where health systems are dysfunctional. The development of LHW programmes should take place alongside health systems strengthening. In addition, LHW need adequate support, particularly if they are expected to undertake an increasingly wide range of tasks
  • The roles of LHWs should not be considered in isolation but rather in relation to the wider primary health care team as well as the health system and society more broadly
  • While the tasks of LHWs will vary across settings, there may be a role for international level guidance in specifying standards regarding registration; curricula and job descriptions; training approaches; and treatment guidelines.

                                                                 
                                                       
Day 5 - 7  Traditional birth attendants
Questions

  • If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?
  • What discrete intrapartum and early postnatal care tasks/skills might well-trained and supervised TBAs safely provide for women? What tasks/skills might they safely provide for newborn babies?
  • With an eye towards optimizing the mix of available frontline health workers, including TBAs, for intrapartum and early postnatal care: Please share your experience in your locale (e.g., category of frontline workers present, how their tasks allocated and by whom, whether work allocation is efficient in the sense of non-duplication, nature supervision, support and reporting).

Emerging themes and issues:

  • Appropriately trained and supported TBAs have an important role in increasing coverage of basic MNH care relevant to MDGs 4/5, especially in countries where service gaps still exist
  • While most are comfortable with TBAs taking on a health education and promotion role, some are uncomfortable with the idea of TBAs providing intrapartum care (their typical role) or theraputic interventions (misoprostol for PPH prevention or resuscitation for birth asphyxia)
  • Most members emphasize the importance of strong linkages among TBAs and facility-based health care providers and on measures to build/ensure this
  • The importance of training, support, supervision/regulation of TBAs to ensure safe practice
  • The positive effects of forging partnerships among TBAs and other frontline workers
  • The need for a formal process of integrating TBAs with the peripheral health system;
  • TBA training is an interim measure while health systems are strengthening vis a vis access to skilled birthing care. Several contributors have raised concerns regarding the potential poor health consequences of policies that limit the TBA’s role in intrapartum care, and the potential fragmentation of care when one focuses on the service provider rather than the woman.

 

Program Examples


In terms of improving the quality of services delivered by lay health workers, Nomtuse Mbere of South Africa discusses using technologies such as mobile phones and telemedicine. In this region doctors and midwives are in short supply and lay care workers are heavily relied upon for education and prevention.

In Nepal they employ Female Community Health Volunteers (FCHV) in the role of lay health workers. Roshani Laxmi Tuitui includes the following in their role: counseling to mothers, vaccination education, distribution of Vitamin A, temporary FP methods and counseling on HIV/AIDS.

Daniel Wibowo of Indonesia adds that in addition to all of the roles of the lay health workers already discussed in this forum, these workers are role models for healthy living for others in their communities. Health cadres in Indonesia do not do interventions, they are used for education and risk identification.

Kenya, notes Jane Otai, has a pilot project involving training CHWs to administer Depo Provera. These CHWs are trained in counseling, storage, injection administration, and disposal of used needles. This pilot project is using self-nominated community volunteers who are usually semi-literate but have a high desire to serve their communities.

Chandrakant Lahariya shares some of the history of lay health workers in India. In the 1970s there was a huge increase in community healthy workers. This role all but disappeared in the 80’s. Under the National Rural Health Mission in India a new cadre of lay workers was born. These workers are called ASHA or Accredited Social Health Activist. There are now over 700,000 ASHAs working in rural and remote parts of the country.

Kamlesh Jain of India discusses the use of Rural Medical Assistants. Kamlesh recommends changing their title to not include the word “rural” as it belittles their profession and subtly indicates that they are not good enough for the urban populace. Kamlesh also encourages regular promotions, salary hikes and continuing education for this cadre.

Jaafar Heikel of Morocco shares a unique examples of using lay persons in the role of health workers. First, IMAMS – religious individuals who conduct prayer within the Mosque – were asked to educate the public on condoms and sexually transmitted infections. This is a place where discussion of this nature would usually be considered taboo, but due to the respect for this individual this was a very successful programme.

In Haiti, Adrienne Allison of USA adds that for more than 20 years they have been successfully using community health workers to deliver vaccinations and injectable contraception.

Chris Morgan of Australia shares his experiences with lay health workers in rural Nepal and Tibet. This role is voluntary in these settings and therefore to be successful this population needs other motivation such as increase in self worth, increasing their standing in the community and greater integration into the local health system.

                                                                 
                                                       
Additional important points/ questions

  • Overall message: Lay health worker (LHW) programmes need to be embedded in both the wider health systems and the local communities.
  • Lay health workers (LHWs) are being used across a wide range of settings and undertake varied tasks to improve MNH. Practices need to be improved, evidence-based and appropriate to local settings. Depending on the local needs and views LHW activities mainly range from prevention/promotion to simple therapeutic tasks.
  • Suggested factors contributing to effective LHW programmes:
    –    appropriate initial and ongoing training
    –    evidence-based guidelines and/or manuals to support practice in the field
    –    supportive supervision from other cadres at the PHC level
    –    regular supplies of drugs and equipment
    –    a robust referral network
    –    appropriate forms of encouragement.
  • A wide-ranging agreement: There is a need for TBAs in resource poor settings, as long as coverage gaps exist.
  • It is widely accepted that appropriately trained and supported TBAs can increase the basic MNH care relevant to MDGs 4 and 5, especially in countries where significant service gaps still exist.
  • Most participants were comfortable with TBAs providing promotional interventions e.g.
  • –    skilled antenatal care and delivery
  • –    immunization
  • –    contraception
  • Some participants were reluctant with TBAs providing: intrapartum care or therapeutic interventions (e.g. using misoprostol for PPH prevention or resuscitation for birth asphyxia).

                                                                 
                                                       
Post-forum survey results

        NA 
                      

References and resources

        NA

                     

Next Steps

  • The contributions from the forum will be synthesized, summarized and presented at the first 'scoping' meeting of various stakeholders (around 20) in Geneva, Switzerland, 6-8 December 2010.
  • The outcome of this meeting will be a limited number of key questions and critical outcomes that will initiate the guidance development process.
  • Questions where there is consensus already, widespread use in practice and no safety issues will be noted but will not be discussed further.
  • Questions where there is controversy, uncertainty about benefits and harms, applicability issues, differences in implementation across settings will form the basis of the guidance work.
  • The questions will be further refined after the meeting and will lead to the conduct of new systematic reviews or updates of existing ones. We hope to conduct a review of country case studies as well.
  • We will post the outcome of the December meeting to the community. We hope to inform the community about our progress, timeline and seek additional feedback during the course of this project.
  • The work will be coordinated by a working group in WHO that includes staff from the departments of Reproductive Health and Research, Making Pregnancy Safer, Child and Adolescent Health, Human Resources for Health, HIV/AIDS and two partnerships, Alliance for Health Policy and Systems Research and Global Health Workforce Alliance and the Norwegian Knowledge Centre for Health Services. The Department of Reproductive Health and Research is the focal point for this project

                      

Organizing groups 
World Health Organization, Department of Reproductive Health and Research (WHO/RHR), Geneva

Contributing experts/facilitators 
  • Olufemi Oladapo, Olabisi Onabanjo University, Nigeria
  • Dr Metin Gülmezoglu, World Health Organization, Department of Reproductive Health and Research (WHO/RHR)
  • Simon Lewin, Norwegian Knowledge Centre for the Health Services  and the Medical Research Council of South Africa
  • Lynn Sibley, Emory’s School of Nursing, USA

Steering committee
  • Metin Güulmezoglu, WHO/RHR
  • Maggie Usher-Patel, WHO/RHR
  • Katie Richey, WHO/RHR
  • Olufemi Oladapo, Olabisi Onabanjo University, Nigeria
  • João Paulo Dias De Souza, WHO/RHR
  • Asa Cuzin-Kihl, WHO/RHR
  • Christina Fusco, IBP

Moderators
  • Asa Cuzin-Kihl, WHO/RHR
  • Christina Fusco, IBP