HRH in Maternal Health Performance Discussion Paper_2_290410

8/9/2019 HRH in Maternal Health Performance Discussion Paper_2_290410

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1 | P a g e Human Resources for Health Knowledge Hub

Maternal, Neonatal & Reproductive Health

Discussion Paper 1 - 2010

Human Resources for Health

Knowledge Hub

http://www.med.unsw

.edu.au/HRHweb.nsf/page/home

DiscussionPaper2

Towardsacomprehensiveapproachtoenhancingtheperformanceofhealthworkersinmaternal,neonatalandreproductivehealthatcommunity

level:learningfromexperiencesintheAsiaandPacificRegions

AngelaDawson2010


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Dawson, A., (2010). Towards a comprehensive approach to enhancing the performance

of health workers in maternal, neonatal and reproductive health at community level:

learning from experiences in the Asia and Pacific Regions, Sydney. Human Resources for

Health Knowledge Hub, University of New South Wales.

http://www.med.unsw.edu.au/HRHweb.nsf/page/home

We would like to acknowledge the MNRH technical input of Dr Natalie Gray from the

Burnet Institute on behalf of Compass, the Womens and Childrens Health Knowledge

Hub.

http://www.burnet.edu.au

We would like to thank Drs John Dewdney and John Hall for their comments on thismanuscript.

For further information and copies of the literature review contact

[email protected]


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IntroductionAddressing the barriers and constraints faced by health workers and managers is a key

component of health system strengthening and improving the quality of health care in

low and lower middle income countries in the Asia and Pacific regions. A number of

reports (de Savigny and Adam 2009; WPRO/WHO 2009) have highlighted the lack of

knowledge available to policy makers and practitioners concerning tools and

approaches that have proved useful in addressing human resources for health (HRH)

challenges in similar contexts. Such knowledge serves to support informed decision

making and helps countries prioritise the limited resources available for systemsstrengthening. There is therefore a need to understand what tools work in specific

settings and to identify lessons from successful (and unsuccessful) reform efforts that

can be applied by countries with comparable objectives. However, assessing what

constitutes a successful HRH intervention, and the extent to which it translates into

enhanced management, team and individual health worker performance that impacts

upon health outcomes at community level, depends on coordinated approaches and

efficient monitoring and evaluation systems.

This discussion paper presents a comprehensive approach to the assessment of

individual health worker, team and HRH management performance in the context of

health system strengthening and the achievement of Millennium Development Goal 5

(MDG 5). It provides examples of lessons learned in the planning, implementation and

evaluation of HRH interventions in maternal, neonatal and reproductive health (MNRH)

at the community level in the Asia and Pacific regions and considerations for enhanced

performance in this area. These conclusions are based on some key findings of a

narrative synthesis of the peer reviewed and grey literature selected using a defined

search strategy and inclusion criteria. A copy of this document is available upon request.


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ContentsIntroduction ............................................................................................................................................. 3The need for a focus on HRH in MNRH at community level ................................................................ 5Cadres at community level and their contribution to MNRH outcomes ................................................. 5The structure of MNRH services at community level ............................................................................ 8What is effective HRH performance in MNRH at community level? .................................................. 10Aligning HRH and MNRH service delivery planning, implementation and evaluation for

improved performance ....................................................................................................................... 12Aligning HRH performance with other aspects of the health system framework......................... 14Monitoring and evaluating HRH performance in MNRH at community level..................................... 16Aligning HRH performance fields with health system strengthening criteria and MDG 5 ............ 16

Aligning health system framework building blocks with progress towards the Millennium

Development Goals ............................................................................................................................. 18HRH approaches in countries that have made progress towards MDG 5 ............................................. 21Sri Lanka .............................................................................................................................................. 21Malaysia ............................................................................................................................................... 22Scaling up experiences and the contribution of HRH interventions ..................................................... 23Indonesia.............................................................................................................................................. 23HRH and community engagement: some experiences from the Pacific ............................................... 27Selecting, implementing and evaluating HRH strategies: Ways forward ............................................. 29References ............................................................................................................................................. 31


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TheneedforafocusonHRHinMNRHatcommunitylevelMDG 5 commits the global community to reducing maternal mortality by threequarters

between 1990 and 2015, and ensuring universal access to reproductive health by 2015.

The progress of many countries in South Eastern Asia and Oceania is insufficient to

reach the target if prevailing trends persist. Maternal mortality remains unacceptably

high in many developing countries, with 61% of women delivering alone or with an

unskilled attendant, and moderate or low access to reproductive health services

including family planning (UNDESA 2009b). Weak health systems and low investment

in health care contribute to difficulties in equitable access to quality MNRH care andservices.

A key component of a functional health system is a competent, motivated and well

managed workforce. HRH are essential to the delivery of evidencebased packages of

care to improve reproductive and maternal health outcomes. At the community level

HRH provide care at critical locations that vulnerable populations need to access. Health

workers can also facilitate community empowerment which is central to primary health

care (PHC). The need to develop HRH capacity in MNRH, particularly in nursing and

midwifery at the primary health care level, is a feature of a number of regional (WHO

WPRO 2005; WHO/ SEARO 2006) and country HRH strategic plans (MoH Cambodia

2006; Lao PDR MoH 2009).

Cadresatcommunitylevelandtheircontributionto

MNRH

outcomes

The term community refers to people who share a common sociocultural background,

religion or habitat. This includes vulnerable high burden populations who reside in a

variety of settings such as geographically isolated villages, urban slums or on borders.

Communities may also be marginalised due to religion, ethnicity, language, and culture.

Communitybased care is care provided by primary health workers (who may or may

not include traditional healers and birth attendants) and structures to community

groups. Also expressed as community orientated primary health care, this notionintegrates the concept of primary health care aimed at individuals with population


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based services by including clinical services, epidemiology and health promotion as

elements of communitybased care (Van Weel and De Maeseneer 2008). Community

based care and services are provided to households, sometimes described as home

based, and may be in the form of outreach services to villages.

Human resources at community level can be broadly categorised into three main

groups: nursing and midwifery professionals, community health workers, and

traditional or cultural practitioners. Workers in other sectors, such as school teachers

and community development workers, may also be involved in the provision of MNRH

care and services. The term skilled birth attendant (SBA) is generally applied to

workers in the nursing and midwifery cadre (WHO ICM FIGO 2004). However, in some

circumstances community health workers receive specialised training in midwifery,

qualifying them as SBAs.

The term community health workers (CHWs) is used to describe practitioners who are

usually selected, trained and work within the communities from which they come

(Lehmann, Freidman et al. 2004). It is not possible to define CHWs or create a standard

set of functions for them as CHW tasks are assigned according to the local conditions

(WHO 1989). CHWs perform a broad range of tasks in MNRH which include curative,

preventive and promotive functions. These include health education and promotion,

advocacy, community mobilisation, dispensing reproductive health commodities anddrugs, basic clinical interventions, and referral. In addition, CHWs perform a mix of

health service functions and community development functions, the latter involving

mobilising the community to improve their social and economic as well as health status.

Examples of cadres within the CHW category in the Asia and Pacific regions are family

welfare assistants (Mridha 2009), peer health educators (Walker 1998), mobile

obstetric maternal health workers (Teela, Mullany et al. 2009) and female community

health volunteers (Shrestha 2003).

Traditional birth attendants (TBAs) are cultural workers engaged in MNRH whose

practice is based on the sociocultural and religious context of the communities in which

they work. TBAs in some countries are independent of the health system and

considered alternative or complementary to Western medicine. TBAs are not formally

trained although they may attend short training course offered by UN agencies (UNFPA

1996; Lan and Dunbar 2003), local NGOs (Parco 2000) or Ministries of Health

(Ronsmans, Endang et al. 2001). They are often not formally employed but receive

direct payment from their clients in the community. However, in some contexts, such as

in Samoa, they are licensed to assist in deliveries and are supervised by midwives (WHO2008a). TBAs may also be involved in referring women to services and providing socio


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cultural support. A number of names are given to TBAs depending on the context. For

example they are referred to as Hilots in the Philippines (MangayAngara 1981),

Dunkun Bayi in Indonesia (Chen 1976) and Yalewa vuku in Fiji (Morse 1981).

This diversity between and among nursing and midwifery professionals, community

health workers, and traditional or cultural practitioners at community level is

summarised at Figure 1 below. In addition, MNRH providers can be salaried or

unsalaried, they undertake different service functions, and are self employed and/or

engaged by the public service and/or nonstate sector. In addition, they may perform

their duties in the community in which they reside, or as part of an outreach service.

Figure1MNRH personnel at community level: cadres, remuneration, function,employer and place of work

Nursing/

midwifery/

communityhealth

worker/

traditional/

cultural/peripheral

worker

Salaried/feeforservice/

voluntary

Specialist/generalist/curative/

promotive/preventive

Public/privatepractitioner

/

NGO/faithbased/selfemployed

Resident/outreach

worker/facilitybased

CommunityMNRHworkers

Cadre

Remuneration

Servicefunction

EmployerPlaceofwork

HRH make a major contribution to MNRH in communities. The density of skilled birth

attendants has been found to impact upon maternal health outcomes (Anand and

Brnighausen 20042005). In almost all countries where SBAs attend more than 80% ofbirths, the maternal mortality ratio (MMR) is less than 200 per 100,000 live births


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(World Bank 1999). The importance of this correlation has led to the adoption of the

proportion of births attended by a SBA as an MDG 5 indicator with the target of 90%

coverage by 2015 (UNCPD 1999). There is also evidence that other cadres at community

level can make important contributions to MNRH. Community health workers (CHWs)

have been shown to have an impact upon preventing neonatal deaths (Bari, Mannan etal. 2006; Baqui 2008; Baqui, ElArifeen et al. 2008) and recovery rates of mothers who

had post natal depression (Rahman, Malik et al. 2008). This has been achieved through

CHW identification of key clinical signs and symptoms, referral and health education.

Peer health educators can contribute to increased reproductive health knowledge and

to some extent improved attitudes linked to delaying timing of the first sexual

experience and safer sexual behaviour (MatickaTyndale 2006). Although there is little

evidence that the practice of trained traditional birth attendants (TBAs) can have an

impact on maternal mortality, they may reduce perinatal and neonatal deaths and

stillbirths (Sibley, T.A. et al. 2007).

ThestructureofMNRHservicesatcommunitylevelCommunitybased MNRH care can involve homebased and/or outreach services.Homebased refers to care and services that are delivered in the patients or consumers

home. This may include births that take place in a womans home or visits made to the

family home to distribute family planning commodities. Outreach includes visits that

are made by health workers who reside in one village or community to another

community, or the visits that midwives or auxiliary nurses make to communities. These

outreach services can be delivered in a purposebuilt structure sometimes known as an

aid post or at a central point in the community such as a community meeting place, a

youth centre or a market. The range of MNRH care and services at community level and

the staff involved are summarised in Table 1 below.


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Table1Levels of community health practice, possible care and services and staffinvolvedLevel Possiblecareandserviceinthecommunity StaffHomebased Normal delivery by skilled birth attendant

including basic obstetric and newborn care, and

referral if needed

Family planning

Commodity distribution (e.g. condoms, othercontraceptives, insecticidetreated bed nets

(ITNs)

Health education during pregnancy (including

sexual & reproductive health education) & birthpreparation

Postpartum/postnatal care for mother & baby

Identifying/referring newborn illness

ResidentincommunityCHWs, volunteers,

TBAs

Outreach

(Aid Post/

dispensary)

Normal delivery by skilled birth attendant

including basic obstetric and newborn care, and

referral if needed

Antenatal care, vaccination

Family planning

Diagnosis and treatment of sexually transmittedinfections

Commodity distribution (e.g. condoms, other

contraceptives, ITNs)

Health education during pregnancy (including

sexual & reproductive health education) & birthpreparation

Postpartum/postnatal care for mother & baby

Identifying/referring newborn illness

VisitingPublic, private &

NGO

midwives, nurses,

nurse/midwife

assistants, CHWs,allied healthworkers


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WhatiseffectiveHRHperformanceinMNRHatcommunitylevel?The achievement of improved reproductive and maternal health outcomes is reliant on

effective HRH performance and quality MNRH service delivery. Yet, despite the

importance of the relationship between HRH and MNRH care and services, there is little

discussion concerning the complex interaction of the components of effective HRH and

quality MNRH practice at the various levels. This includes an examination of

contributing factors such as sociocultural norms, health system structures, and

ideologies that impact upon the accessibility, acceptability and quality of health

services. An improved understanding of these factors may enhance efforts to undertake

a comprehensive approach to planning, implementing and evaluating health care.

ThecomponentsofqualityHRHandMNRHservicedeliveryThere are a number of components of HRH and MNRH practice that contribute to

effective performance. These are outlined in Figure 2.

Figure2Components of quality HRH and MNRH service delivery

EffectiveHRH

practice

QualityMNRH

carepracticeImpacton

MDG 5

Leadership

&

management

ComponentsofqualityMNRH servicesdeliveryatcommunitylevel

ComponentsofqualityHRHpracticeatcommunitylevel

Appropriate

Education&

Competence

Supportive

working

environment

Policy,

legislation&

regulation

ContinuityComprehensive

ness

Equity&

access

Technical

currency

Community

relevance

Community

participation


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Quality MNRH care and services are based upon the continuum of care model that

involves health practitioners working with the community, family and individuals. This

comprises four components: Reproductive Care, Antenatal Care (ANC), Intrapartum

Care and Postnatal Care (PNC). These components include effective education about

reproductive rights and dissemination of contraception; quality antenatal care(including nutritional advice and supplements, malaria prevention services, tetanus

vaccination, and Prevention of Parent to Child Transmission of HIV); skilled attendance

at birth; and postnatal care for mother and baby (including advice and support for

breastfeeding and routine immunisations). Under the Continuum of Care model

(PMNCH 2009) these services need to be closely integrated with functional linkages

between different service providers (Kerber, de GraftJohnson et al. 2007). This

contributes to the provision of comprehensive coverage of care that must be acceptable

and accessible to vulnerable and marginalised groups. In addition, these packages of

care must be based on the latest evidence which ensures their technical currency and berelevant to the needs of the community. The latter can be achieved through consultation

processes within the community in which the care is to be delivered. However, the

quality of this care is largely dependent on health worker performance as well as the

willingness of women to access it and families to pay for it.

Quality HRH practice involves effective leadership, performance management,

incentives, appropriate remuneration, and workforce planning selection and

recruitment. Supportive working environments are required that foster teamwork andpartnerships and provide adequate infrastructure, logistics, equipment, transport and

communication systems. This also includes policies that concern the health, safety and

welfare of staff as well as family friendly working environments. Appropriate numbers

of staff are required with a skill mix that is aligned with the MNRH service delivery

requirements. Quality education and training are necessary to build the necessary

knowledge, skills and attributes to meet the required competencies to perform a

specific function within a profession. National HRH policy and legally binding conditions

are necessary to regulate health worker training and practice to ensure quality and

public safety. Community participation is an essential. Community members should not

only be considered to be users of services delivered by health workers, but also as

contributing to the delivery of homebased interventions through volunteer activity or

as household members. All of these components need to be aligned with all HRH

policies and practices (horizontal integration) and the objectives of the organisation

(vertical integration) (Baird 1988). Effective implementation of these approaches

requires that HR systems are acceptable to managers and health workers which is

critical in ensuring enhanced performance outcomes (Guest 1997).


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The relevance, accessibility, efficiency, acceptability, effectiveness and impact of HRH

performance can be assessed at the individual health worker, team and management

levels. Indicators or measurable variables of performance can be based on these criteria

and be drawn from the components of HRH practice outlined above. Hornby and Forte

(2002) present a systems approach to understanding HRH performance according toinputs, processes and outputs. Key inputs in the HRH system include the skill mix of the

staff, the available numbers of HRH in relation to the case load and population served,

and the associated staff costs in relation to the total health expenditure. Process level

HRH indicators are concerned with efficiency. This includes the organisational

environment in which people work and how it affects how people deliver care and

services as well as how efficiently HRH are utilised in the service. At the individual

health worker level this denotes the efficiency of care and services such as case

management and patient satisfaction. This process area includes task performance

measurements which focus on technical aspects, as well as contextual performance oftasks outside core job practices such as involvement in village health committees

(Michie 2003) which contribute to acceptability measures.

The effectiveness and impact of HRH performance is reflected in changes in health

outcomes. An output indicator might be the proportion of women who deliver their

babies with a skilled birth attendant, which has strong links with health outcomes such

as MMR, or the contraception prevalence rate. However, a comparison can also be made

linking health outcomes and the workforce in order to gauge the impact of HRHperformance. For example, an HRH outcome indicator might be the contraception

prevalence rate in relation to family welfare workers employed or the adolescent

fertility rate in relation to number of peer health educators. This combines population

based data with servicebased data.

AligningHRHandMNRHservicedeliveryplanning,implementationandevaluationforimprovedperformanceIt is only at the impact and outcome levels that HRH indicators make a link with MNRH

care and services and health outcomes. However, impact indicators, for example the

number of home visits made by peer health educators in relation to the percentage of

women aged 1549 years currently using contraception, fail to reveal the complex

interactions that have contributed to performance at the process and input level. This

highlights the need to link planning, implementation and evaluation across both HRHand service delivery areas at the input, process, and impact levels using common


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criteria. The diagram in Figure 3 depicts a broad ranging approach to HRH and MNRH

service delivery planning, implementation and evaluation. This involves equalconsideration of HRH and MNRH service components and associated input, process and

output indicators throughout the entire planning and implementation cycles. Impact

indicators are therefore considered alongside input and process indicators in order toaddress MNRH needs and affect outcomes. In addition, indicators need to be developed

according to six criteria (relevance, accessibility, efficiency, acceptability, effectiveness

and impact) to ensure comparability and alignment across all components and levels.

For example, at the input level an HRH indicator such as the percentage of trainees from

the local community provided with knowledge and skills on reproductive health in a

given year can be considered alongside a service delivery indicator such as the

percentage of clients given counselling on family planning.

Figure3 Aligning HRH and MNRH Service delivery components, indicators and levels

Community

relevance

Technical

currency

Equity&

access

Comprehen

siveness

Continuity

Inputs

Process

Outputs

MNRH Needs&objectives

MNRH Outcomes

HRH

Components

Service

delivery

components

Criteria

*Relevance

*Accessibility

*Efficiency

*Acceptability

*Effectiveness

*Impact

Criteria

*Relevance

*Accessibility

*Efficiency

*Acceptability

*Effectiveness

*Impact

Policy,

regulation&

legislation

Supportive

working

environment

Community

participation

Education,

training &

competence

Leadership

&

Management

Adapted from Hornby & Forte (2002)


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AligningHRHperformancewithotheraspectsofthehealthsystemframeworkSo far we have only considered HRH in relation to service delivery, which constitutesonly two of the building blocks of the WHO health systems framework (2007). If we are

to consider HRH performance improvement in relation to health systems strengthening

and MDG 5, the perspective needs to be multidimensional. HRH and service delivery are

also linked to information systems, the supply of medical products, vaccines and

technologies, financing, leadership and governance. Table 2 provides some examples of

indicators at input, process and output levels in reproductive health across the six

building blocks of the WHO health systems framework. Plotting indicators in a matrix

format provides an opportunity to see how indicators in each of the areas might relate

so that appropriate measures can be selected for assessing performance across all

areas. Indicators can be developed and selected according to the six criteria (relevance,

accessibility, efficiency, acceptability, effectiveness and impact) discussed above which

ensures a coordinated approach to planning, implementation and evaluation.

At the process level the HRH indicators are concerned with efficiency and when they are

linked in with the other building blocks of the health system contribute to strengthening

efforts in a horizontal manner. Output level indicators focus on the effectiveness of HRH.

This involves a more vertical approach to achieving the objectives of the organisationswhich include improving reproductive health outcomes as shown in table 2. These

approaches are central to strategic human resource management and the fit of HRH

activities (Wright 1992) with the goals of health systems strengthening and

achievement of MDG5.


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Table2Examples of HRH performance indicators alongside others in the health systemrelated to reproductive health

HRH ServiceDelivery

Finance Leadershipandgovernance

Informationsystems

Supplyofmedicalproducts,vaccinesandtechnologies

Input level

Percentage of

femaletrainees

provided

with

knowledge &skills on

reproductivehealth in a

given year

Number of

servicedelivery

points

offering

familyplanning

services

Percentage of

public sectorexpenditures

on

contraceptive

commodities

Existence of

nationalpopulation

and

reproductive

health policy& plans

Percentage of

women 1549 years

currently

using modern

methods ofcontraception

included inroutine data

collection

Percentage of

servicedelivery

points stocked

with family

planningcommodities

according toneeds

Process level

Proportion of

CHWs

trained in

familyplanning &

reproductivehealth

Percentage

of clients

given

counsellingon family

planningduring a year

Proportion of

budget spent

on

contraceptivesat community

level

Use of

national

policy targets

in monitoringand

evaluationplans at

communitylevel

Collection of

data

according to

nationalprotocols at

communitylevel

Percentage ofcontraceptive

supplies that

are wasted

Output

Percentage of

CHWs

trained in

relation tothe number

of clientswho received

counselling

Percentage

of clients

expressing

satisfactionwith the

counsellingservices

received

Cost of

contraceptive

in relation to

average familyincome

Number of

targets met/

protocols

followed asper policy

Number of

routine data

collections as

per protocolin household

surveys

Available

number of

contraceptives

in relation toneed

Selected Indicators adapted from (ESCAP 2003)


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MonitoringandevaluatingHRHperformanceinMNRHatcommunitylevelMeasuring the effectiveness of HRH interventions and the extent to which they translate

into enhanced management, as well as team and individual health worker performance

that impacts upon health outcomes at community level, depends on adequate

monitoring and evaluation. However, it is necessary, given the discussion above, that

this is linked to and coordinated with other monitoring and evaluation activities. For

example, the results of health worker performance management at the micro level

should feed into a larger HRH quality improvement system that itself forms part of

overall health system improvement and, if appropriate, scaled up solutions.

AligningHRHperformancefieldswithhealthsystemstrengtheningcriteriaandMDG5A whole of system approach to performance demands that HRH evaluation is integrated

into a quality assurance approach which is linked to health systems strengthening and

the achievement of the MDGs. Table 3 below sets out the areas by which HRH

performance can be evaluated alongside criteria for assessing health systems

strengthening and associated targets for MDG 5. The HRH performance fields on the left

are categorised according to their relationship to policy, management systems, and

education and training. Indicators can be drawn from the three fields at input, process

and output levels. The focus on certain fields and use of key indicators will be

determined by the context. At community level in MNRH, for example, community

participation in HRH is critical across these fields. Indicators in this case will reflect

community contribution to HRH performance through engagement in HRH processes

such as selection and recruitment, supervision, and education and training. The list also

indicates that indicators be developed to address individual, team and managementperformance.

HRH performance is affected by the sociocultural context and is dependent upon the

availability of infrastructure, medications, supplies, functional lines of communication

and funding. Better coordination across health systems areas will help to ameliorate

some of these issues; however, issues at the superstructure level may pose the greatest

difficulties. Significant investment is required in economic and structural change which

must be linked with health system improvements. However, an evaluation of GAVI


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health systems strengthening found that almost all countries are using funding for

downstream activities (e.g. to support and deliver immunisation and maternal and

child health services) rather than upstream in sectorwide change or reform (GAVI

HLSP 2009).

HRH indicators can be used as evidence by which an assessment of overall performance

can be made according to five criteria listed under health system strengthening (Islam

2007). Equity refers to the allocation of resources or the treatment of outcomes among

different individuals or groups. Efficiency concerns the allocation of resources in a way

that ensures obtaining the maximum possible overall benefit, as well as technical

efficiency, or the achievement of the maximum possible sustained output from a given

set of inputs. Access relates to physical as well as financial access while quality concerns

the ability to meet implied or stated needs. Financial and institutional sustainability areabout the capacity of the system to continue its normal activities into the future. These

criteria can be used by health system building blocks individually and collectively to

assess overall health system strengthening.

The MDG 5 targets serve as higher level impact indicators but also need to be traceable

through process and input indicators. These also frame the content areas of

performance in maternal mortality and universal access to reproductive health. MDG 5

is also interrelated with other Millennium Development Goals (WHO 2008b). Maternal

mortality, for example, is closely linked to newborn mortality and therefore progress on

MDG 5 will also influence efforts to reduce child mortality (MDG 4). Progress in

achieving MDG 3, promoting gender equality and womens empowerment, will help in

achieving MDG 5. Increasing primary education (MDG 2) for girls and eradicating

extreme poverty and hunger (MDG 1) are means to empower women and will positively

influence the achievement of MDG 5.


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Table 3 Aligning HRH Performance fields with Health System Strengthening criteria and

MDG 5

HRHPerformancefields HealthSystemsstrengtheningcriteria

MDG5associatedtargets

Policy

PresenceofNationalanddistrictHRHpolicythataddressescommunity level&MNRH

Presenceofjobclassificationsystemthatincludescommunitycadres

Compensation&benefitssystemusedinaconsistentmannertodeterminesalaryupgrades&

awards

Formalprocessesforrecruitment,hiring,transfer,promotion &community involvement

Employeeconditionsofservicedocumentation (e.g.,policymanual)

Presenceofaformalrelationshipwithunions(ifapplicable)

Presenceofaformalrelationshipwithcommunity organisations

Registration,certification,orlicensingisrequiredforcategoriesofstaffinordertopractice

ManagementsystemsStaffsupply,retention&lossRatioofCHWs,nurse&midwives&TBAsatcommunity leveltopopulation (2.28)(Speybroeck 2006)

ThedistributionofHRHinurbanandruralcommunities

Distributionbyage,DistributionofHRHbysector(state/non state),Distributionbysex

DistributionofHRHbyoccupation, specializationorotherskillrelatedcharacteristic

Proportionofstaffindualemployment /employed atmorethanonelocation

Numberofvacancies,postsfilled,duration injob,proportionofHRHunemployed

Hoursworkedcomparedwithhoursrostered

Presenceofhumanresourcesdatasystem

Theexistenceofafunctioning HRplanningsystem

Daysofabsenteeism amonghealthworkers

Ratioofentrytoandexitfromthehealthworkforce

Communityinvolvement inrecruitment &selection

Proportionofnationallytrainedhealthworkers

HRdedicatedbudgetandcommunityservicesidentified

Personneladministration/employeerelationsSalary:averageearnings,averageoccupationalearnings&incomeamongHRH

Healthandsafetyintheworkplace,standardoperatingprocedures,protocols&manuals

Incentives,monetaryandnonmonetary, teamwork,practice, functional partnerships

PerformancemgtJobdescriptionsarepresent

Supervision(especiallyclinicalsupervision)schedule, communityinvolvement insupervision

Percentageofsupervisionvisitstothefieldplannedthatwereactuallyconducted

Thereisaformalmechanismforindividualperformance planningandreview

Communityinvolvement inperformance management

Peerreviewmechanisms

Levelofjobsatisfaction,Levelofstaffmotivation

Education,training&competenciesExistenceofaformalinservicetrainingcomponent forallcadres

Existenceofamanagement andleadershipdevelopmentprogram

Mechanismsfor

involving

community

&

HRH

in

pre

/post

service

curriculum

development

&

review

Relativenumberofspecifictasksperformedcorrectlybyhealthworkers/adherencetoprotocol

Clientsatisfaction,Noof Patientcontacts

Noofcommunitymeetingsattended&evidenceofcommunityparticipation

Equity: AreHR

distributedequitablyor

inequitably?

Access: Isaccessto

careinhibitedbylackof

competentpersonnel

inrural&distant

communities?

EfficiencyIspersonneluseinefficientbecause

oflackofHRplanning

&coordination?

Quality:Isthequality

ofcare

affected

by

accesstoqualified

personnel,provider

behaviouror

incompetence?

Sustainability:Are

personnelsupportedor

givenincentives? (ie

throughcommunity

financingsystem?)

5.1 Maternalmortality

ratio:reducebythree

quartersby2015

5.2 InhighMMR

countries:50%ofall

birthstobeassistedby

aSBAby2010&60%

by2015,Globally,85%

ofallbirthsassistedby

skilledattendantsby

2010,85%&90%by

2015(UNCPD1999)

5.3 Percentageof

women1549currently

usingcontraception

5.4 Annualnumberof

birthstowomen1519

yrsper1,000women in

thatagegroup

5.5 Percentageof

women1549yrs

attendedatleastonce

duringpregnancyby

SBA&percentage

attendedbyany

provideratleastfour

times

5.6 Women whoare

fecund&sexually

activebutarenotusing

anymethod of

contraceptionand

reportnotwantingany

morechildrenor

wantingtodelaythe

birthofthenextchild

Adapted from (Dieleman 2006; Islam 2007; Dal Poz, Gupta et al. 2009; UNDESA 2009)

AligninghealthsystemframeworkbuildingblockswithprogresstowardstheMillenniumDevelopmentGoals


19/35




It is clear that harmonising monitoring and evaluation systems across all components in

each of the health system framework building blocks is essential in order to make

progress towards all of the MDGs. This in turn strengthens the health system itself.

Figure 4 illustrates how aligning all building blocks in the WHO health system

framework ensures that they are considered together in relation to planning,implementation and evaluation. The six sides of the hexagon represent the six

components of health systems with health needs and objectives determining priorities.

The spiral in the centre, taken from action research (Kemmis 1983), represents the

process involved in addressing health needs and objectives in order to meet all the

MDGs. This includes initial planning, followed by action, monitoring, and evaluating

then revising the plan or modifying the action.

This iterative and constantly changing process of observing, acting and reflecting should

systematically involve all key stakeholders in a coordinated and consistent approach to

the development of indicators and assessments of performance at the input, process,

and output levels. These processes, as well as the components of the health system

building block and the form of the health system framework itself, are affected by

factors in superstructure. These go beyond materials and infrastructure to include

macroeconomics, culture, institutions, power structures, roles and rituals of the society.


20/35




Figure4The relationship between health systems strengthening and achieving theMDGs

ServicedeliveryHRH

Financing

Supply of medical

products, vaccines &

technologies

Information

systemsLeadership &

governance

Inpu t s

Process

Ou tpu t s

Health needs& objectives

MDGs

Geo-political /economic /

Socio-culturalfactors

Geo-political /economic /

Socio-culturalfactors

The approach outlined in Figure 4 provides a comprehensive, three dimensional picture

from a systems perspective that facilitates an understanding of the codetermination of

events so that interventions can be better designed, delivered and proactively modifiedin a consistent and ongoing manner. This means that poor performance can be

identified early at the input stages including the factors that contribute to this

assessment and the ways in which they interact to affect practice. Changes can be made

to complex interventions, management processes can be adapted and if possible

adjustments can be made to accommodate change at the health systems level and

beyond.


21/35




HRHapproachesincountriesthathavemadeprogresstowardsMDG5The discussion so far has focused on conceptual approaches to planning, implementing

and evaluating HRH performance in MNRH at community level but examples of actual

country experience helps to place this in context. Key lessons can be drawn from

countries which have brought about significant reductions in maternal mortality due to

improved access to reproductive health through the provision of essential services.

These lessons highlight the need for an integrated health systems approach to HRH in

MNRH.

SriLankaIn Sri Lanka, the professionalisation, broad coverage and use of midwives (Levine 2007)

has been a central HRH approach in MNRH. Public health midwives (PHM) at

community level cover a population of approximately 3000 people and report to a

supervising public health midwife at the district level. PHMs are clinically competent as

well as being recognised as credible and respected professionals (Rizzuto 2002). The

Ministry of Health undertook a staged process of replacing TBAs with PHMs anddiscontinuing TBA training in an effort to increase skilled attendance at birth at the

community level (de Silva 2007). Demand for TBA services declined from the 1950s

while demand grew for facilities that were easily accessible to remote areas

(Pathmanathan 2003). National management processes ensured that strict training

standards for midwives were maintained during the period of expansion from 1930

1950 and a supervisory structure maintained quality during this phase. PHMs were also

supported by equipment, transport and allowances. In addition, the employment of

relatively lowcost PHMs in Sri Lanka meant affordable access to maternal care at

community level (Pathmanathan 2003). This contributed to the MMR which droppedfrom 250 per 100,000 live births in 1935 to 58 in 2005, while SBAs assisted only about

30 percent of the births in 1940 rising to nearly 90% in 1995 (de Silva 2007). These

initiatives were accompanied by the delivery of an integrated Maternal and Child Health

(MCH) package through health units and the implementation of family planning and

population policies within a functional health system that was underpinned by PHC.


22/35




MalaysiaThe sharp decline in maternal mortality in Malaysia from and MMR of nearly 1500 per

100,000 live births in the 1930s to less than 58 in 2005 (UNDP 2007) was the result of a

number of factors including the establishment and regulation of a new midwifery cadre.

Midwives were deployed as frontline community health workers to provide maternal

care and the number of registered midwives doubled in 1971 and slowly increased over

the next 10 years. In the late 1970s, the eighteen month community midwife training

was upgraded and expanded to include child health and basic outpatient care. The cadre

became known as community health nurses (CHNs), raising their status and improving

the range of MNRH care and services at community level (Pathmanathan 2003).

CHNs are supervised by certified nurse midwives (3 year basic training + 12 month

midwifery course) or public health nurses (additional 1 year training) (Pathmanathan

2003). They use a competencybased approach founded on protocols and manuals

involving a written supervisory checklist that covers facility maintenance, record

keeping and interpersonal skills. Supervisors provide CHNs with regular onthespot

feedback on clinical and programmatic issues (Rizzuto 2002). Supervisory midwives

provide support for CHNs in emergency situations through either handson clinical

assistance or by facilitating referral to hospitals. Midwifery practice at community level

is guided by a manual of procedures and clinical protocols produced in 1988. A colour

coded risk approach for the referral of pregnant women was implemented in 1983 andinservice management training using problem solving approaches is used to overcome

communication and attitudinal barriers between midwives and nurses in rural services

and hospital staff. Midwives also receive inservice training in clinical skills as well as in

community mobilisation. Despite a lack of evaluation studies showing an impact upon

referral, it is likely that the HR interventions contributed to the increase in hospital

admissions for complicated cases (Pathmanathan 2003).

In Malaysia, TBAs were included as part of the health care system; they receive training,

a delivery kit and are registered. TBAs are also paid for each delivery they attend which

they were required to report, enabling their delivery kit to be restocked. Midwives are

trained to value these traditional practitioners and work alongside them. TBAs provide

an important supportive role at community level including being present at births with

CHNs, accompanying women to hospital and assisting with post natal and newborn

care. This approach has been successful in not only encouraging safe delivery practices

but it hastened the move from TBA to midwife delivery (Rizzuto 2002) thereby

improving skilled attendance at delivery. The ratio of government midwives to live

births improved from more than 1:300 in 1960 to about 1:120 (Pathmanathan 2003).


23/35




These lessons indicate that the mobilisation of HR cadres such as midwives and CHWs,

with an emphasis on clinical performance and community participation, is critical at

community level. Involving TBAs in the continuity of care alongside SBAs addresses the

sociocultural needs of women. Successful HR approaches show that attention must be

placed on collaboration between health workers, regular supervision and qualitytraining. The professionalisation of midwifery or of a skilled birth attendant cadre at

community level is an effective strategy alongside the creation of an informal sector of

human resources for MNRH comprised of community members themselves. There is a

clear need to develop and build upon current local organisational structures that are

part of the social fabric of the community. Experiences in Sri Lanka and Malaysia

demonstrate this. However, all these achievements were accompanied by ongoing

phases of health systems development with modest expenditures on maternal health

care and services. It is important to note the contribution of policy at national level,

poverty reduction strategies, gender empowerment, education and rural developmentinitiatives.

ScalingupexperiencesandthecontributionofHRHinterventionsThe scaling up experiences of countries can contribute to an understanding of howselected components of HRH practice can be expanded in unison with policy

development, financial commitment and improved leadership. Structural and economic

changes can both enhance HRH performance and constrain it. This requires rigorous

monitoring and evaluation practice so that decision makers can be alerted to potential

problems so that adjustments be made. The Indonesian experience of scaling up the

village midwifery program can provide some useful insights in HRH at community level

in MNRH.

IndonesiaFollowing the International Nairobi conference in 1987, at which governments pledged

to reduce maternal mortality by half by 2000, the Indonesian government launched the

Village Midwifery Program. This was in response to maternal mortality of over 400 per

100,000 live births and neonatal mortality of 32 per 1000 live births. The aim was to

place a SBA in every village to provide MNRH care and services. Three years later in

1993, 60,000 community midwives had been deployed and about 20,000 maternity huts

had been established with community participation (Utomo 2008). Midwife density

increased from 0.2 to 2.6 per 10,000 people between 1986 and 1996 (Shankar,Sebayang et al. 2008).


24/35




Twenty years after its inception, progress towards reducing MMR and NMR has been

made, but it was not as large as expected. MMR in 2003 was 307 per 100,000 live births

and the NMR was 20 per 1000 live births. Despite its success in increasing density of

SBAs and reducing socioeconomic inequalities in professional attendance at birth, the

focus on outreach services has meant that the poor, particularly those in rural and

remote areas, experienced increasing difficulties in accessing emergency obstetric care

in hospitals (Hatt, Stanton et al. 2007).This is probably the result of lack of responsive

referral systems (e.g. transport), low cultural acceptability which reduces demand for

services, and the high outofpocket cost of emergency obstetric care (EmOC) services

(Ronsmans, Endang et al. 2001). Despite the calculation that the ratio of village

midwives per 2389 population would translate to roughly one midwife per 54 births

per year (Hatt, Stanton et al. 2007), evaluations showed that midwives actually attended

fewer births than this. As a result, the midwives obstetric workload was generally low

and affected by competition with TBAs, as well as the wide geographic spread of

households. Consequently midwives were not continually using and improving their

clinical skills. Midwives case management skills were also generally substandard due

to the rapid nature of the program and low quality of preservice training (Utomo

2008). Supervision and mentoring of midwives was not adequate and their varied

duties and often vague job descriptions also meant that many midwives worked in

isolation with few opportunities for job support or learning. This had a strong impact on

retention (Shankar, Sebayang et al. 2008).

A number of modifications were made to the program (summarised in Figure 5) which

coincided with contextual factors which significantly impacted upon the scale up. These

included the economic crisis of 1997 which precipitated the introduction of a social

safetynet program for the poor, and in 2003 decentralisation led to an increase in

district level decision making (Utomo 2008). The program modifications included

lengthening the preservice midwife training and providing short inservice training

and skillsbased retraining (McDermott, Beck et al. 2001). Management practices were

improved including performance management which incorporated supervision and

career development (Hennessy, Hicks et al. 2006a; FKUGM/WHO 2009). Financial

incentives were found to be sufficient to retain midwives in remote areas although non

financial reasons affected their relocation to these settings once established with their

family (Ensor, Quayyum et al. 2009). Financial incentives were introduced for TBAs to

encourage referral to midwives (Analen 2007). A Workload Indicators of Staffing Need

(WISN) approach was introduced to improve workforce planning and management in

the newly decentralised context (KolehmainenAitken 2009). This bottom up approach

began with health centre midwives. Midwife training and selection was also improved,leading to better coverage and competence (UPCD 2003; Hennessy, Hicks et al. 2006b).


25/35




These changes were made along with the development of EmOC, audits, and

introduction of a comprehensive health policy in 2001 that included a Making

Pregnancy Safer strategy (Utomo 2008).

Figure5 Examples of structural and economic changes in Indonesia which impacted uponimproved HRH performance

Villagemidwiferyprogram:IndonesiaStructuralchangesAdvocacy&leadership:safemotherhoodseminarsinthemid1990sinvolving

PresidentSuharto

HRHcoverage:SBA% increasedfrom34to62%by1998

Improvededucationandskills:pre&inservicecompetencybased

Monitoring&

evaluation:

clinical

audits

used

to

assess

performance

Policy: MPSstrategy2001

Managementpractice:NationalMoH midwifetraining&placementplan,Clinical

PerformanceDevelopmentandManagementSystemforNursesandMidwives,

WISN toolforworkforceplanning

Communityparticipation: VillageIntegratedservicepost(posyandu)

EconomicchangesIncreasedfinancialresources&coordinationoffinances:Extendedsalarysupport &

formalisedadministrativeoversighteasedthetransitiontoprivatepractice

Procurementsofdrugs,equipmentetc:Districtcontrolthroughdecentralisation

Areasthatrequirestrengthening: clinical&communicationtraining,mentoring&supervision,jobdescription,ensuringadequatecaseloads,HISonprivateproviders

&legalityofsoloprivatenurseproviders

(Shankar, Sebayang et al. 2008; Utomo 2008; Heywood and Harahap 2009)

There are some key lessons that can be learned from the Indonesian village midwife

scale up effort. Shankar et al group these into essential elements and monitoring points

for scaling up skilled birth attendance(2008). These and other elements are included in

Figure 6 below. There are similarities with the UNFPA ICM model (2006) for scaling up

community midwives, with an emphasis on the pertinent HR aspects of certification,

supervision, clear responsibilities and realistic workload. Community participation and

engagement contribute to the enabling environment which is further supported by

political and economic reform brought about by resource mobilisation and effective

management and leadership. Ongoing monitoring and evaluation facilitates the

modification of programs to suit the changing environment, contributing to the


26/35




sustainability of interventions. Indonesias experience shows that HRH efforts must be

coordinated with an efficient health information system, financial commitment, the

appropriate supply of medical products, vaccines and technologies, quality service

delivery and leadership and governance. Shankar et al (2008) emphasises a systems top

down and bottom up approach. This highlights the need for support from the existinghealth system in order to accommodate expansion that ensures quality as well as

equity.

Figure6Essential elements and monitoring points for scaling up skilled birthattendance

Healthsystemsapproachto

ScalingupHRHat

communitylevelinMNRH

Political &economic

commitment

Monitoring&

evaluationsystem

Clearscope ofpractice

Certification

QualityTraining

Supervision

Realisticworkload

Communityparticipation

Stewardship,resource

mobilisation&

management

Adapted from (Shankar, Sebayang et al. 2008) and (UNFPA ICM WHO 2006)


27/35




HRHandcommunityengagement:someexperiencesfromthePacificCommunity participation is an essential component of people centred PHC (WHO 1978).

Households are critical but under rated actors in the health sector (Wagstaff 2004).

They are not only users of services delivered by professionals but also producers of

health through the delivery of homebased interventions and in their everyday health

behaviours (Wagstaff 2004). Community members can be actively engaged in HRH

processes which can be facilitated by health workers with the support of HR

management structures. This includes involvement in MNRH service delivery but also

engagement in the selection and recruitment of HRH and their supervision and training.

Recruiting staff from the areas where they are posted and work may improve retention

and possibly effectiveness (IntraHealth 2008). This provides a strong link with

communities ensuring community empowerment as well as acceptance and support of

health workers (Chaya 2007). However, the current extent to which the community is

organised and motivated affects their involvement in HRH, output and performance

(Mangelsdorf 1988).

There are some documented experiences from the Pacific where community members

are involved across key areas of HRH policy, management and education and training in

MNRH. However, it is important to note that there is a paucity of detail due to a lack of

data and rigorous evaluation. This is the result of a deficiency of analytical studies, poor

implementation studies and a reliance on descriptive and project evaluation studies

(ten HoopeBender, Liljestrand et al. 2006). Rigorous qualitative studies are also

required to better understand the sociocultural environment of demand, service

delivery and health care management for MNRH (LevittDayal 2009). Documented HRH

experiences in the Pacific are also mostly isolated examples and there is usually no

reference to other aspects of the health system or impact on health outcomes. This

illustrates the pressing need to identify a more coordinated approach to planning,

implementing and evaluating HRH interventions. Evaluation of HRH interventions on

their own will not shed useful light on how they relate and interact with other

interventions in order to gauge what has been achieved and how.

At community level there is much documented cooperation between the nursing and

midwifery cadres, volunteers and TBAs. For example, in Vanuatu 180 active Aid Posts in

villages are staffed by volunteers and supervised by a general nurse at the dispensary

level, who in turn is supervised by a nurse practitioner, who also acts as manager, a


28/35




midwife and general nurse in the Health Centre (MoH Vanuatu 2004). In Samoa, TBAs

work closely with nurses and midwives and are legally recognised as allied health

workers and receive their training from midwives (WHO 2008a). Supervision is

promoted by linking it to accreditation required for all PHC health staff, so there is a

strong imperative to be involved in inservice training (Burnet Institute 2007). Both ofthese examples have not been thoroughly studied in context and with respect to the

extent to which they were part of an integrated health systems approach. No monitoring

and evaluation data is available. Although both Samoa and Vanuatu have high SBA

coverage with 92.9 percent of births being attended by SBAs in Vanuatu and 100

percent in Samoa (WPRO/WHO 2009), maternal mortality ratios (MMR) are different.

The Hospitalreported MMR in Samoa is 3 deaths per 100,000 live births while in

Vanuatu an overall ratio is reported as 70 per 100,000 per live births (WPRO/WHO

2009). The reasons for this difference are complex. Nurse and midwife personnel

coverage in Samoa and Vanuatu is reported at 17 per 100,000 (WHO 2009), which ishigher than the figure of 2.28 considered as the minimum number of personnel

required to delivery essential interventions to achieve the MDGs (Speybroeck 2006).

However, Vanuatus population of 246,000 is spread over 83 islands which impacts

upon access to services whereas Samoas population of 179,000 is more densely

concentrated on two main islands (UNDESA 2009a).

Socioeconomic indicators and inequity may also go some way towards explaining the

different MMRs in the two Pacific Island nations, which are both categorised as lowermiddle income countries (World Bank 2008). The human development index (HDI) of

both countries has improved over the last 10 years, although Samoa has a higher HDI

(0.771) than Vanuatu (0.693). There is considerable gender inequality and disparities in

economic and political decision making in both nations, with Vanuatus genderrelated

development index (GDI) being lower than Samoas in relation to the countrys HDI

(UNDP 2009). In addition, general government expenditure on health as a percentage of

total expenditure on health in 2005 was 83.0 in Samoa and 65.0 in Vanuatu (WHO

2009). In Vanuatu, the governments spending on health is reportedly roughly half of

that spent by governments in surrounding countries (UNFPA 2008).

Despite potentially useful models of community and health worker partnership, HRH

performance, health system functionality and maternal health outcomes are

constrained by a number of issues in the Pacific. In Vanuatu for example, maternal

health is constrained by geography, investment and low female participation in decision

making. These examples indicate the need for massive structural and economic change

requiring an integrated systems approach to planning, monitoring and evaluating HRH

practice. Isolated examples of improved performance are useless on their own andhighlight the problem with shortterm projectbased approaches to health development


29/35




that lack comprehensiveness. This concurs with the recent report on Making Aid

Effectiveness Work for Family Planning and Reproductive Health which emphasises the

need for adequate funding and indicators to monitor progress toward MDG5 (Dennis

2009).

Selecting,implementingandevaluatingHRHstrategies:WaysforwardThis discussion paper has demonstrated that enhancing HRH performance is a complex

process that requires the use of a number of strategies across HRH as well as in otherhealth system areas. It highlights the need for a more rigorous and well coordinated

approach to HRH planning, implementation and evaluation by linking activities across

the health system. The following points summarise practical guidelines for enhancing

HRH performance in MNRH at community level gleaned from country experiences.

HRH practices and their respective indicators need to be aligned or horizontallyintegrated with other HRH components as well as vertically integrated with the

HRH objectives of the organisation.

HRH initiatives need to be horizontally aligned with other building blocks of thehealth system and vertically integrated with MNRH targets in order to achieve

health system strengthening and progress towards MDG 5.

HRH performance monitoring and evaluation must take context intoconsideration and performance in key areas that are linked to district, provincial

and national objectives and at individual, team and management levels including

the participation of community members.

Health systems strengthening criteria provide a useful way of consideringimprovement according to standards that are acknowledged across other parts

of the health system.

Structural and economic change is required to ensure successful implementationof HRH interventions. This must be well monitored, incremental and aligned

with a whole of system approach to change that is both bottom up and top down

Superstructure factors can have a major impact upon HRH; however, a whole ofsystem approach may help to ameliorate this through effective monitoring and

evaluation systems that facilitate ongoing modifications.

Monitoring and evaluation systems must employ rigorous methods drawing onperspectives from analytical studies including epidemiological evidence as well

as qualitative research.


30/35





31/35




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