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Transcript of Smith PPTs
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“With Women” Midwives for Afghanistan
Reproductive HealthWorkforce Developmentin Afghanistan
2002 - 2009
Jeffrey Smith, MD, MPH
Asia Regional Technical Director
Jhpiego
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Presentation Outline
Review the reproductive health situation in Afghanistan Discuss the human resource constraints
Describe some key considerations in workforcedevelopment/task shifting in reproductive health
Present the results of interventions in Afghanistan
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RH Situation 2002
High maternal and newbornmortality (MMR 1600 / 100 000 LB)
Few RH providers 40% facilities with female staff 467 midwives in country
Non-uniformity of qualification Out of date skills
No functional schools for trainingmidwives – schools closed by Taliban
RH de-emphasized in medical curriculum Disarray of system for supporting human
resources for health STRATEGY: support the education and
deployment of large numbers ofmidwives rather than doctors
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Task Shifting
Putting clinical capabilityin hands of appropriateperipheral workers sothat key components ofhealth care can bediffused to greatestnumber of people.
Should not be atemporary fix!
But a professional focus!
4
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What works, who works, and where?
Health Center IntrapartumCare Strategy Training of Midwives
Staffing of Health Centers
Health system linkages
Capability in Basic EmOC Clarity about “skilled attendant”
Policy support for clinical authority
Educational system to achievecompetency and capability
Lancet 2006Maternal Survival Series
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Workforce Assessment & Planning
Array of semi
trained, partially
skilled workers
NEEDHAVE
Core group of
leaders and
academicsGroup of managers
and teachers
Bulk of personnel
should be service
providers
Cries of crisis:
“Something is
better than
nothing”
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Normatizing the Health Workforce
Re-establish health systemaccountability
Census of health workers Including where they work
Testing: knowledge + skills
Phased (re)deployment Registration and licensure Upgrade programs Education programs
Set selected practical policies Immediate need and long term
view Emergency Development
Staff
functioning
as midwives
QualifiedAlmost
qualifiedUnqualified
License and
Deploy
Upgrade
Standardize
and Retain
Retrain to
qualification,
Redeploy
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Importance of Standardization
Single, standard approach toupgrading RH workforce maybe more efficient, especiallyin post-conflict settings
Fragile health systems don’thave resources to compareand contrast different, non-uniform approaches atmacro level
Uniformity of professional andcommunity expectation,supervision, supply, etc.
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Policy and Structure
Basic Package of Health Services
Maternal Health / RH Service delivery guidelines Guide for re-establishing services and in-service training/pre-
service education
National MW education policy Midwifery job description
Single, unified national midwifery curriculum
Assessment materials and criteria
of students graduation and licensure of clinical facilities quality of care and clinical certification of schools school accreditation
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Standardization in Action
Standard curriculum anddetailed teaching resources
National accreditation system Based on “recipe” for
establishing and running amidwifery school
Structured technicalassistance framework
Increased local capacity and
improved ability to supporttraining programs and schoolsin remote or insecure areas
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Keep it clinical
Ensure that the focusremains on clinical skilldevelopment
MW program in Afghanistan
was SHORTENED from 3years to 2 and unnecessarytopics were removed Semester 1: Normal
Pregnancy
Semester 2: Complications Semester 3: Family Planning,
RH and Child Care
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Keep it local
Retention, deployment,
selection and education
all related:
local control increases local
commitment
Train midwives where
they are needed
Focus on local, “micro-
deployment”
Caveat: ensure adequate
educational and clinical
capacity
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Results 2002 – 2009
5 midwifery schools re-opened and 26 newmidwifery schools established
Midwifery deployment 1961 new midwives 85% deployed 86% working as midwives
Health centers with 1+
female health worker:25% 83%
Health centers staffed with 1+ midwife: <10% 61%
Standardized system to improve quality in midwifery
services and education
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Working as Midwives, 2009
P r o gr am
C ur r en t l y s t u d yi n g
E nr ol l e d
Gr a d u a t e d
Dr o p- o u t s
% Gr a d u a t e d
D e pl o y e d /
E m pl o y e d
% D e pl o y e d / E m p
l o ym en t of gr a d u a t
e d
C ur r en t l yw or k i n g
( a s of M a y ,2 0 0 9 )
% c ur r en t l yw or k i
n g of gr a d u a t e d
C ur r en t l yw or k i n g
of d e pl o y e d / em pl
o y e d
IHS 167 1232 1103 129 90% 890 81% 754 68% 85%
CME 509 886 858 28 97% 785 91% 694 81% 88%
Total 676 2118 1961 157 93% 1675 85% 1448 74% 86%Local CME schools have greater
success than regional IHS programs.
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Deliveries by Skilled AttendantsSelected Provinces/Districts
Tarkhar:
from 12%
to 21%
Herat:
from 13%
to 27%
Examples of
increase in
skilled birth
attendant
coverage at
birth:
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Professionalization of MidwiferyAfghan Midwives Association
Founded in 2005
Provincial branch in mostprovinces
Roles: Advocacy
Professional development
Networking and support
Has raised personal andprofessional stature ofmidwifery “This is the first time I have
ever belonged to anything
other than my own family. I
feel proud to be a midwife.”
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Reflection on “Gender”
Task shifting should not become
Clinical Shortcutting
Shortcuts in medical education vs.Shortcuts in midwifery education
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Conclusions
Vibrant maternal health / reproductive healthworkforce must be composed substantially ofmidwives
Midwives must be empowered professionallyand deployed rationally
Consistency in the service delivery andeducational system is essential for midwives tohave skills and retain skills
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Acknowledgements
Ministry of Public Health,Afghanistan
Donors – USAID, WorldBank and EuropeanCommission
Non GovernmentalOrganization partners,WHO, UNICEF, andmany other supporters ofmidwifery
Staff and students of allmidwifery schools
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Thank you
Questions?
Comments?
Observations?