Progress towards Millennium Development Goals 4 & 5: strengthening human resources for maternal, newborn and child health

In the decade since the World Health Report’s call to action on human resources for
health (HRH) 11], tremendous global attention has been placed on strengthening human resources for
MNCH, notably by increasing the sheer number of health providers and improving the
quality of MNCH care they provide. Though the density of skilled providers falls below
the World Health Organization (WHO) threshold for obtaining adequate MNCH care of
23 per 10,000 people in 53 of the 68 priority countries 9] the recent attention on HRH has shed light on ways to ensure that the right health
workers are in the right place providing the right care for women and children.

The right health workers

Though it is well-recognized that having a skilled birth attendant (SBA) is one of
the most reliable predictors of positive maternal and neonatal health outcomes, policies
supporting SBAs in the workforce are often lacking. For example, in Africa, where
the global health crisis is most severe, very few national HRH policies exist to guide
the training and deployment of the health workforce for maternal, newborn and child
health 12]. Where policies are in place, the divide between policy and practice, including imbalances
in the workforce structure and distribution, stands in the way of equitable service
access, suggesting the need for a more strategic approach to health workforce management
13]. One promising tool to understand and begin to address this divide is a task analysis
of the current national MNCH workforce, a method in use in Mozambique to streamline
the workforce 14]. Such approaches are critical first steps towards developing the proper policies
and plans required to improve the effectiveness of the public health workforce in
a sustainable way 15,16].

Once the right type of worker is determined for the country’s needs, recruiting the
right candidates and educating them in the right manner–providing up-to-date competency-based
education with adequate mentored practice–is critical. With significant increases
in donor funding for pre-service education (PSE), evidence in this area has grown
in recent years. Johnson and colleagues developed a conceptual model of the health
impacts of PSE and collected evidence of the effectiveness of common PSE input. They
also highlighted the essential role of clinical preceptors, the importance of professional
regulation and the effectiveness of targeted recruitment of students from rural and
low-resource settings to improve health worker retention 17].

…In the right place

Even in countries where sufficient numbers of providers are available in urban centers,
severe shortages exist in rural areas. In Guinea, for example, where fewer than half
of nurses and a fifth of midwives needed for MNCH care are currently available, supply
is lowest in rural areas, and demand is expected to grow by 22% in the next decade
18]. In countries where home births are still the norm, one promising method for providing
women with the care they need is through community health providers. One recent analysis
summarizing community-centric methods to reduce postpartum hemorrhage (PPH) reported
that across 18 programs, a total of 6,732 women took misoprostol—a uterotonic that
does not require refrigeration—and that distribution by community health providers
more than doubled coverage rates compared with health workers and ANC providers alone
19].

Another way to ensure that critical services are available where women need them is
by retaining the skilled maternal health providers currently in place, by improving
job satisfaction and formal supervision systems, for example 20].

…Providing the right care

Making the most of the current workforce to meet demands is essential in addressing
the HRH crisis for MNCH care. Task-shifting has improved access and quality of care
in a variety of settings 21-23]. For example, in Mali, trained matrones—or auxiliary midwives–were as skilled at
performing active management of the third stage of labor (AMTSL) as their SBA colleagues,
which led to a shift in national policy 24]. Though task-shifting may not be the entire answer to the health workforce crisis,
it certainly is part of the solution 25].

Quality and coverage of interventions known to improve maternal and newborn health
vary widely. For example 90% of women have at least one ANC visit, but only 30% of
babies receive a postnatal (PNC) visit 26]. A systematic review found that staff shortages were the most consistent barrier
to quality emergency obstetric care 27]. Though increasing health worker numbers and quality–“scaling up” and “skilling
up”–are both needed, Fauveau, Sherratt and de Bernis encouraged prioritizing quality
over numbers, and shared a framework for addressing scaling up quality midwifery at
the community level 28].

The most common “go-to” intervention to improve provider performance is in-service
training. Though training is essential to develop the health workforce, Gaye and Nelson
argue that training alone cannot succeed without addressing common pitfalls, including
uncoordinated training, training the wrong people, taking workers from their jobs
to be trained, and inattention to other factors needed to support workers’ new skills,
such as organizational support and supportive supervision 29]. Another recent review of in-service training approaches reports that multiple learning
modalities, clinical simulations, repetition, and practice with feedback are effective
techniques, while passive instruction, such as reading and lecture, have limited effect
30].

Fritzen (2007) proposed using a lens to look at what the workforce ‘can do’ and what
it ‘will do’ to help improve service quality, citing clear terms of employment, supervision,
employee recognition, incentives to improve motivation, and performance management
techniques 12]. Quality improvement approaches have been widely used with some success, such as
in Tanzania, where performance in newborn care improved, but newborn resuscitation
performance remained unchanged 31].