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Background: In Belgium, the Planning Commission for Medical Supply is responsible for monitoring human resources for health (HRH) and ultimately proposing workforce quotas. It is supported by the Planning Unit for the Supply of the Health Professions. This Unit quantifies and forecasts the workforce in the healthcare professions on the basis of a stock and flow model, based on trends observed in the past. In 2019, the Planning Unit asked the KCE (Belgian Health Care Knowledge Centre) to develop additional forecasting scenarios for the midwifery workforce, to complement the standard historical trend approach. The aim of this paper is to present the development of such forecasting scenarios. Methods: The Robust Workforce Planning Framework, developed by the Centre for Workforce Intelligence in the UK was used to develop alternative midwifery workforce scenarios. The framework consists of four steps (Horizon scanning, Scenario generation, Workforce modelling, and Policy analysis), the first two of which were undertaken by KCE, using two online surveys and five workshops with stakeholders. Results: Three alternative scenarios are proposed. The first scenario (close to the current situation) envisages pregnancy and maternity care centred on gynaecologists working either in a hospital or in private practice. The second scenario describes an organisation of midwife-led care in hospitals. In the third scenario, care is primarily organised by primary care practitioners (midwives and general practitioners) in outpatient settings. Conclusions: The Robust Workforce Planning Framework provides an opportunity to adjust the modelling of the health workforce and inform decision-makers about the impact of their future decisions on the health workforce. [ABSTRACT FROM AUTHOR]

Background: Poor Maternal and Child Health (MCH) outcomes pose challenges to India's ability to attain Goal-3 of the Sustainable Development Goals (SDGs). The government of India strengthened the existing network of frontline health workers (FHWs), under its National Rural Health Mission in 2005 and subsequent National Urban Health Mission in 2013 as a strategy to mitigate the shortage of skilled health workers and to provide affordable healthcare services. However, there is a lack of robust national-level empirical analysis on the role of maternal engagement with FHWs in influencing the level of maternal and child health care utilisation and child health outcomes in India.Methods: Using data from the nationally representative Indian National Family Health Survey (NFHS) 2015-2016, this paper aims to investigate the intensity of engagement of FHWs with married women of child-bearing age (15-49 years), its influence on utilisation of maternal and child healthcare services, and child health outcomes. Our empirical analyses use multivariate regression analyses, focusing on five maternal and child health indicators: antenatal care visits (ANC) (4 or > 4 times), institutional delivery, full-immunisation of children, postnatal care (PNC) (within 2 days of delivery), and child survival.Results: Our analysis finds that maternal engagement with FHWs is statistically significant and a positive predictor of maternal and child health care utilisation, and child survival. Further, the level of engagement with FHWs is particularly important for women from economically poor households. Our robustness checks across sub-samples of women who delivered only in public health institutions and those from rural areas provides an additional confidence in our main results.Conclusions: From a policy perspective, our findings highlight that strengthening the network of FHWs in the areas where they are in shortage which can help in further improving the utilisation of maternal and child healthcare services, and health outcomes. Also, the role of FHWs in the government health system needs to be enhanced by improving skills, working environment, and greater financial incentives. [ABSTRACT FROM AUTHOR]

Background: A competent, enabled and efficiently deployed health workforce is crucial to the achievement of the health-related sustainable development goals (SDGs). Methods for workforce planning have tended to focus on 'one size fits all' benchmarks, but because populations vary in terms of their demography (e.g. fertility rates) and epidemiology (e.g. HIV prevalence), the level of need for sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) workers also varies, as does the ideal composition of the workforce. In this paper, we aim to provide proof of concept for a new method of workforce planning which takes into account these variations, and allocates tasks to SRMNAH workers according to their competencies, so countries can assess not only the needed size of the SRMNAH workforce, but also its ideal composition (the 'Dream Team').Methods: An adjusted service target model was developed, to estimate (i) the amount of health worker time needed to deliver essential SRMNAH care, and (ii) how many workers from different cadres would be required to meet this need if tasks were allocated according to competencies. The model was applied to six low- and middle-income countries, which varied in terms of current levels of need for health workers, geographical location and stage of economic development: Azerbaijan, Malawi, Myanmar, Peru, Uzbekistan and Zambia.Results: Countries with high rates of fertility and/or HIV need more SRMNAH workers (e.g. Malawi and Zambia each need 44 per 10,000 women of reproductive age, compared with 20-27 in the other four countries). All six countries need between 1.7 and 1.9 midwives per 175 births, i.e. more than the established 1 per 175 births benchmark.Conclusions: There is a need to move beyond universal benchmarks for SRMNAH workforce planning, by taking into account demography and epidemiology. The number and range of workers needed varies according to context. Allocation of tasks according to health worker competencies represents an efficient way to allocate resources and maximise quality of care, and therefore will be useful for countries working towards SDG targets. Midwives/nurse-midwives who are educated according to established global standards can meet 90% or more of the need, if they are part of a wider team operating within an enabled environment. [ABSTRACT FROM AUTHOR]

A crucial question in the aim to attain MDG5 is whether it can be achieved faster with the scaling up of multi-purpose health workers operating in the community or with the scaling up of professional skilled birth attendants working in health facilities. Most advisers concerned with maternal mortality reduction concur to promote births in facilities with professional attendants as the ultimate strategy. The evidence, however, is scarce on what it takes to progress in this path, and on the 'interim solutions' for situations where the majority of women still deliver at home. These questions are particularly relevant as we have reached the twentieth anniversary of the safe motherhood initiative without much progress made. In this paper we review the current situation of human resources for maternal health as well as the problems that they face. We propose seven key areas of work that must be addressed when planning for scaling up human resources for maternal health in light of MDG5, and finally we indicate some advances recently made in selected countries and the lessons learned from these experiences. Whilst the focus of this paper is on maternal health, it is acknowledged that the interventions to reduce maternal mortality will also contribute to significantly reducing newborn mortality. Addressing each of the seven key areas of work -- recommended by the first International Forum on 'Midwifery in the Community', Tunis, December 2006 -- is essential for the success of any MDG5 programme. We hypothesize that a great deal of the stagnation of maternal health programmes has been the result of confusion and careless choices in scaling up between a limited number of truly skilled birth attendants and large quantities of multi-purpose workers with short training, fewer skills, limited authority and no career pathways. We conclude from the lessons learnt that no significant progress in maternal mortality reduction can be achieved without a strong political decision to empower midwives and others with midwifery skills, and a substantial strengthening of health systems with a focus on quality of care rather than on numbers, to give them the means to respond to the challenge. [ABSTRACT FROM AUTHOR]

Background: In the United Republic of Tanzania, as in many regions of Sub-Saharan Africa, staff shortages in the healthcare system are a persistent problem, particularly in rural areas. To explore staff shortages and ways of keeping workers in post, we ask, (a) Which cadres are most problematic to recruit and keep in post? (b) How and for what related reasons do health workers leave? (c) What critical incidents do those who stay face? (d) And why do they stay and cope?Methods: This is a multi-method paper based on analysis of data collected as part of a cross-sectional health facility study supporting maternal and reproductive health services in the United Republic of Tanzania. Qualitative data were generated through semi-structured interviews with Council Health Management Teams, and Critical Incident Technique interviews with mid-level cadres. Complementary quantitative survey data were collected from district health officials, which are used to support the qualitative themes.Results: Mid-level cadres were problematic to retain and caused significant disruptions to continuity of care when they left. Shortage of highly skilled workers is not only a rural issue but also a national one. Staff were categorised into a clear typology. Staff who left soon after arrival and are described by 'Look, See and Go'; 'Movers On' were those who left due to family commitments or because they were pushed to go. The remaining staff were 'Stayers'. Reasons for wanting to leave included perceptions of personal safety, feeling patient outcomes were compromised by poor care or as a result of perceived failed promises. Staying and coping with unsatisfactory conditions was often about being settled into a community, rather than into the post.Conclusions: The Human Resources for Health system in the United Republic of Tanzania appears to lack transparency. A centralised monitoring system could help to avoid early departures, misallocation of training, and other incentives. The system should match workers' profiles to the most suitable post for them and track their progress and rewards; training managers and holding them accountable. In addition, priority should be given to workplace safety, late night staff transport, modernised and secure compound housing, and involving the community in reforming health services culture and practices. [ABSTRACT FROM AUTHOR]

Background: Most African countries are facing a human resources for health (HRH) crisis, lacking the required workforce to deliver basic health care, including care for mothers and children. This is especially acute in rural areas and has limited countries' abilities to meet maternal, newborn, and child health (MNCH) targets outlined by Millennium Development Goals 4 and 5. To address the HRH challenges, evidence-based deployment and training policies are required. However, the resources available to country-level policy makers to create such policies are limited. To inform future HRH planning, a scoping review was conducted to identify the type, extent, and quality of evidence that exists on HRH policies for rural MNCH in Africa. Methods: Fourteen electronic health and health education databases were searched for peer-reviewed papers specific to training and deployment policies for doctors, nurses, and midwives for rural MNCH in African countries with English, Portuguese, or French as official languages. Non-peer reviewed literature and policy documents were also identified through systematic searches of selected international organizations and government websites. Documents were included based on pre-determined criteria. Results: There was an overall paucity of information on training and deployment policies for HRH for MNCH in rural Africa; 37 articles met the inclusion criteria. Of these, the majority of primary research studies employed a variety of qualitative and quantitative methods. Doctors, nurses, and midwives were equally represented in the selected policy literature. Policies focusing exclusively on training or deployment were limited; most documents focused on both training and deployment or were broader with embedded implications for the management of HRH or MNCH. Relevant government websites varied in functionality and in the availability of policy documents. Conclusions: The lack of available documentation and an apparent bias towards HRH research in developed areas suggest a need for strengthened capacity for HRH policy research in Africa. This will result in enhanced potential for evidence uptake into policy. Enhanced alignment between policy-makers' information needs and the independent research agenda could further assist knowledge development and uptake. The results of this scoping review informed an indepth analysis of relevant policies in a sub-set of African countries. [ABSTRACT FROM AUTHOR]

Developing countries are currently struggling to achieve the Millennium Development Goal Five of reducing maternal mortality by three quarters between 1990 and 2015. Many health systems are facing acute shortages of health workers needed to provide improved prenatal care, skilled birth attendance and emergency obstetric services - interventions crucial to reducing maternal death. The World Health Organization estimates a current deficit of almost 2.4 million doctors, nurses and midwives. Complicating matters further, health workforces are typically concentrated in large cities, while maternal mortality is generally higher in rural areas. Additionally, health care systems are faced with shortages of specialists such as anaesthesiologists, surgeons and obstetricians; a maldistribution of health care infrastructure; and imbalances between the public and private health care sectors. Increasingly, policy-makers have been turning to human resource strategies to cope with staff shortages. These include enhancement of existing work roles; substitution of one type of worker for another; delegation of functions up or down the traditional role ladder; innovation in designing new jobs;transfer or relocation of particular roles or services from one health care sector to another. Innovations have been funded through state investment, public-private partnerships and collaborations with nongovernmental organizations and quasi-governmental organizations such as the World Bank. This paper focuses on how two large health systems in India - Gujarat and Tamil Nadu - have successfully applied human resources strategies in uniquely different contexts to the challenges of achieving Millennium Development Goal Five. [ABSTRACT FROM AUTHOR]

Background: Over the last five years, international development organizations began to modify and adapt the conventional Performance Improvement Model for use in low-resource settings. This model outlines the five key factors believed to influence performance outcomes: job expectations, performance feedback, environment and tools, motivation and incentives, and knowledge and skills. Each of these factors should be supplied by the organization in which the provider works, and thus, organizational support is considered as an overarching element for analysis. Little research, domestically or internationally, has been conducted on the actual effects of each of the factors on performance outcomes and most PI practitioners assume that all the factors are needed in order for performance to improve. This study presents a unique exploration of how the factors, individually as well as in combination, affect the performance of primary reproductive health providers (nurse-midwives) in two regions of Armenia. Methods: Two hundred and eighty-five nurses and midwives were observed conducting real or simulated antenatal and postpartum/neonatal care services and interviewed about the presence or absence of the performance factors within their work environment. Results were analyzed to compare average performance with the existence or absence of the factors; then, multiple regression analysis was conducted with the merged datasets to obtain the best models of "predictors" of performance within each clinical service. Results: Baseline results revealed that performance was sub-standard in several areas and several performance factors were deficient or nonexistent. The multivariate analysis showed that (a) training in the use of the clinic tools; and (b) receiving recognition from the employer or the client/community, are factors strongly associated with performance, followed by (c) receiving performance feedback in postpartum care. Other — extraneous — variables such as the facility type (antenatal care) and whether observation was on simulated vs. real patients (postpartum care) also had a role in observed performance. Conclusion: This study concludes that the antenatal and postpartum care performance of health providers in Armenia is strongly associated with having the practical knowledge and skills to use everyday tools of the trade and with receiving recognition for their work, as well as having performance feedback. The paper recognized several limitations and expects further studies will illuminate this important topic further. [ABSTRACT FROM AUTHOR]

Background: There is a dearth of evidence on the causal effects of different care delivery approaches on health system satisfaction. A better understanding of public satisfaction with the health system is particularly important within the context of task shifting to community health workers (CHWs). This paper determines the effects of a CHW program focused on maternal health services on public satisfaction with the health system among women who are pregnant or have recently delivered.Methods: From January 2013 to April 2014, we carried out a cluster-randomized controlled health system implementation trial of a CHW program. Sixty wards in Dar es Salaam, Tanzania, were randomly allocated to either a maternal health CHW program (36 wards) or the standard of care (24 wards). From May to August 2014, we interviewed a random sample of women who were either currently pregnant or had recently delivered a child. We used five-level Likert scales to assess women's satisfaction with the CHW program and with the public-sector health system in Dar es Salaam.Results: In total, 2329 women participated in the survey (response rate 90.2%). Households in intervention areas were 2.3 times as likely as households in control areas to have ever received a CHW visit (95% CI 1.8, 3.0). The intervention led to a 16-percentage-point increase in women reporting they were satisfied or very satisfied with the CHW program (95% CI 3, 30) and a 15-percentage-point increase in satisfaction with the public-sector health system (95% CI 3, 27).Conclusions: A CHW program for maternal and child health in Tanzania achieved better public satisfaction than the standard CHW program. Policy-makers and implementers who are involved in designing and organizing CHW programs should consider the potential positive impact of the program on public satisfaction.Trial Registration: ClinicalTrials.gov, EJF22802. [ABSTRACT FROM AUTHOR]

Background: Midwives have an essential role to play in preparing for and providing sexual and reproductive health (SRH) services in humanitarian settings due to their unique knowledge and skills, position as frontline providers and geographic and social proximity to the communities they serve. There are considerable gaps in the international guidance that defines the scope of practice of midwives in crises, particularly for the mitigation and preparedness, and recovery phases. We undertook a systematic review to provide further clarification of this scope of practice and insights to optimise midwifery performance. The review aimed to determine what SRH services midwives are involved in delivering across the emergency management cycle in humanitarian contexts, and how they are working with other professionals to deliver health care.Methods: Four electronic databases and the websites of 33 organisations were searched between January and March 2017. Papers were eligible for inclusion if they were published in English between 2007 and 2017 and reported primary research pertaining to the role of midwives in delivering and performing any component of sexual and/or reproductive health in humanitarian settings. Content analysis was used to map the study findings to the Minimum Initial Service Package (MISP) for SRH across the three phases of the disaster management cycle and identify how midwives work with other members of the health care team.Results: Fourteen studies from ten countries were included. Twelve studies were undertaken in conflict settings, and two were conducted in the context of the aftermath of natural disasters. We found a paucity of evidence from the research literature that examines the activities and roles undertaken by midwives across the disaster management cycle. This lack of evidence was more apparent during the mitigation and preparedness, and recovery phases than the response phase of the disaster management cycle.Conclusion: Research-informed guidelines and strategies are required to better align the scope of practice of midwives with the objectives of multi-agency guidelines and agreements, as well as the activities of the MISP, to ensure that the potential of midwives can be acknowledged and optimised across the disaster management cycle. [ABSTRACT FROM AUTHOR]