The human resource crisis in emergency obstetric and newborn care
Globally, 80 percent of live births occur with the assistance of skilled health personnel (a doctor, nurse, or midwife, according to the WHO); however, this rate varies by region and country, and only 59% of women in Sub-Saharan Africa give birth with a skilled attendant present. In addition, the birth attendants who are present are not always sufficiently trained to handle life-threatening complications or provide essential newborn care.
At the epicenter of this challenge stands the issue of human resources for health (HRH): the number of health workers, distribution, motivation, retention, skill mix, morale, professional norms, and, ultimately, the quality of care that they deliver to the population. Sub-Saharan Africa, where the human resource shortage is most dire, has 25 percent of the global burden of disease but only 3 percent of the world’s health workers. Women living in rural areas are most vulnerable as they are more often left without access to life-saving care.
AMDD has focused its HRH work on two key issues – posting and transfer and task shifting – as well as HRH needs for emergency obstetric and newborn care.
Posting & Transfer
Well-functioning government health services are necessary to achieving universal health coverage in low and middle income countries (LMIC). However, the lack of a skilled and knowledgeable health workforce in many LMICs leaves those in need without appropriate and timely care. Posting and transfer (P&T), the practice by which health workers at all levels are assigned posts and transfers, plays a critical role in the distribution of health professionals in the public sector.
Poor P&T practices are driven by multiple factors, including corruption and patronage, dissatisfaction with health worker performance, health worker preference for urban postings, and inefficient human resource management. Despite the widespread recognition of these challenges by global health advocates and policy-makers, little discussion or formal research of P&T has taken place. To address this glaring gap, AMDD and its partners researched the consequences of poor P&T practices and explored policy options to address this issue.
AMDD’s contributions to posting and transfer:
The Health Governance Hub of the Public Health Foundation of India (PHFI), with AMDD support, organized a global consultative meeting on “Posting and Transfer Practices in the Health Sector” in New Delhi, India in April 2013. Read the final report of the meeting here.
In October 2013, AMDD published a foundational open access literature review entitled "Unmasking the open secret of posting and transfer practices in the health sector" in Health Policy and Planning. The review looks at practices that can be described as “mission inconsistent” meaning that they operate in ways that do not maximize health outcomes, and that are inconsistent with prevalent professional norms. The article also proposes research principles to guide future research on P&T.
Stemming from the literature review and the Delhi meeting, AMDD and PHFI co-convened a three day meeting at the Bellagio Center in Bellagio, Italy in 2014. Researchers and policy makers from India, the Middle East, West Africa, North America, and Latin America were invited to deliberate on the issues of P&T, and to consider the potential for a joint research and advocacy platform for P&T. As discussed by the participants, P&T is a complex issue that is shaped by human resources for health constraints, maldistribution of the health workforce, lack of transparency in hiring and posting, and context-specific social and political dynamics. See the final report of the meeting here and short blog post summarizing key takeaways here. Two researchers who attended the meeting conducted country level case studies on posting and transfer in their countries, contributing to an emerging understanding of how P&T operates globally. Both of these case studies are available via open access; the Ghana case study can be found here, and the Nigeria case study here.
In 2014, AMDD and the Public Health Foundation of India (PHFI) held an open satellite meeting on posting and transfer at the Global Symposium on Health Systems Research. A colleague wrote a brief blog summarizing the event here.
Posting and transfer (P&T) was highlighted as a challenge to equitable and transparent health employment and health systems functioning in a policy brief submitted by AMDD and PHFI to the UN Secretary General’s High-Level Commission on Health Employment and Economic Growth’s Expert Group. The Commission’s purpose was to propose intersectoral actions to guide and stimulate the creation of health and social sector jobs to advance inclusive economic growth. The P&T policy brief is publically available on the Commission’s website. In addition, the Expert Group included a discussion of P&T on page 46 of its final report, published in 2016.
Task shifting has served as one of the key strategies employed by governments in sub-Saharan Africa to address their dire shortages of human resources and meet the emergency obstetric care (EmOC) needs of their populations.
The use of Associate Clinicians (ACs)—formerly known as “Non-Physician Clinicians”—to provide clinical care to patients has proven valuable through various studies showing their positive impact on health outcomes, cost effectiveness, and high retention rates in comparison to doctors. ACs have been trained and deployed in over 25 of 47 sub-Saharan African countries to date. Yet, successful implementation of task shifting programs remains a challenge.
AMDD’s contributions to task shifting:
In 2012, AMDD received a grant from University Research Co., LLC (URC) Translating Research into Action (TRAction) to conduct research on the implementation of Associate Clinician cadres for Comprehensive Emergency Obstetric Care (CEmOC) in Zambia, Kenya, Tanzania and Malawi. The aims of this research were to collect and analyze data on AC utilization in each of the four countries, draft case studies on implementation in each context, develop guidance notes for countries considering task-shifting programs, and introduce task shifting cadres and issues in new fora.
AMDD’s Shanon McNab and colleagues from Community Health Promotions Kenya gave a presentation on task shifting for maternal health at the Health Systems Research Conference in Vancouver on November 17, 2016. See the abstract here.