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  H4+  High  Burden  Countries  Initiative   National  Assessments  –  midwifery  workforce     Operational  guidance  and  assessment  framework    

  Prepared  by  the  Secretariat  and  Technical  Working  Group     APRIL  2012.    

 


H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

List  of  abbreviations     CHW           Community  Health  Worker   GHWA     Global  Health  Workforce  Alliance     GD     Group  discussion   H4+     UNAIDS,  UNFPA,  UNICEF,  WB,  WHO   HBCI     High  Burden  Countries  Initiative   HRH     Human  Resources  for  Health   ICM     International  Confederation  of  Midwives   MCIS     Multiple  Cluster  Indicator  Survey   MNH     Maternal  and  Newborn  Health   MoH     Ministry  of  Health   NGO     Non-­‐governmental  organization   PI     Principal  Investigator   PMNCH     Partnership  for  Maternal,  Newborn  and  Child  Health   SoWMy     State  of  the  World’s  Midwifery   ToR     Terms  of  Reference   TWG     Technical  Working  Group   UNAIDS     Joint  United  Nations  Programme  on  HIV/AIDS     UNFPA     United  Nations  Population  Fund   UNICEF     United  Nations  Children’s  Fund   WB     World  Bank   WHO     World  Health  Organization       Any   feedback,   questions   or   remarks   related   to   the   national   assessment,   or   this   guidance   document,  can  be  addressed  to  the  persons  below.    

UNFPA     Name:       Position:     Email:         WHO   Name:       Position:     Email:         Secretariat   Name:       Position:     Email:         Acknowledgements:    

Luc  de  Bernis   Senior  Maternal  Health  Advisor   debernis@unfpa.org  

Blerta  Maliqi   Health  Systems  Technical  Officer   maliqib@who.int  

Jim  Campbell   Director,  ICS  Integrare.     jim.campbell@integrare.es  

With   thanks   to   members   of   the   Technical   Working   Group,   Secretariat   and   external   reviewers   including:   Yves   Bergevin,   Luc   de   Bernis,   Agneta   Bridges,   Jim   Buchan,   Jim   Campbell,   Catherine   Carr,   Rupa  Chilvers,  Laurence  Codjia,  Marjolein  Dieleman,  Vincent  Fauveau,  Kathy  Herschderfer,  Petra  ten   Hoope-­‐Bender,   Sennen   Hounton,   Christel   Jansen,   Peter   Johnson   ,   Jacqueline   Mahon,   Blerta   Maliqi,   Mwansa  Nkowane,  Jeske  Paijmans,  Cindy  Paladines,  Amani  Siyam,  Tana  Wuliji.    

  FRONT  COVER:  Photo  ID  451897.  14/06/2010.  Dhaka,  Bangladesh.  UN  Photo/Kibae  Park.  www.unmultimedia.org/photo/  

 

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

Table  of  Contents       1   Introduction  .................................................................................................................  4   2   Background  ..................................................................................................................  5   2.1   Implementing  partners  .................................................................................................  5   2.2   Planning,  objectives,  output  .........................................................................................  6   3   Process  of  the  National  Assessment  .............................................................................  7   3.1   Preparation  and  Country  Engagement  –  Phase  1  .........................................................  7   3.2   National  assessment  –  Phase  2  .....................................................................................  9   3.3   Synthesis  –  Phase  3  .......................................................................................................  9   4   The  National  Assessment  Framework  ........................................................................   10   4.1   In-­‐country  data  collection  ...........................................................................................  12   4.2   Assessment  tools  ........................................................................................................  12   4.3   Data  analysis  and  identification  of  scenarios  and  costed  policy  options  ....................  12   4.4   Reporting  ....................................................................................................................  13   5   Quality  assurance  and  dissemination  of  results  ..........................................................   14   6   Selected  References  ...................................................................................................   15   Annex  A.  Glossary  and  operational  definitions  .................................................................   17   Annex  B.  Assessment  Framework  -­‐  overview  ...................................................................   19   Annex  C.  Suggested  sources  for  document  review   ...........................................................   26   Annex  D.  Detailed  information  on  the  in-­‐country  data  collection  and  analysis  .................   27   Annex  E.  Typical  information  for  Ethics  Review  Board.  .....................................................   31    

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

1

Introduction  

This  document  contains  background  information,  operational  guidance  and  the  assessment   framework   for   the   High   Burden   Countries   Initiative   (HBCI)   National   Assessments   on   the   Midwifery  Workforce  at  the  Community  Level*.       It   seeks   to   inform   the   Ministry   of   Health   and   other   government   entities,   H4+   agencies,   national  stakeholders  and  development  partners  in  each  of  the  eight  participating  countries   about  the  national  assessments,  and  to  provide  guidance  on  implementation  activities.     Chapter  2   provides   the   background   to   the   H4+  HBCI  and  the  national  assessments  on   the  midwifery  workforce  at  the  community  level.       Chapter  3   outlines  the  process  of  the  national  assessments.     Chapter  4   addresses   the   content   of   the   national   assessment   with   additional   information  in  Annexes  A  –E.     Chapter  5   discusses   mechanisms   to   ensure   the   quality   of   the   assessment,   as   well   as   dissemination   of   the   national   assessment   reports   and   synthesis   report   to   national  and  international  partners.        

 

*

 The  midwifery  workforce  includes  health  care  workers  whose  primary  functions  include  health  care  to  women  in  reproductive   health,  pregnancy,  labour  and  birth  and  to  mothers  and  babies  in  the  postnatal  period  (UNFPA,  ICM,  &  WHO,  2006).  For  the   purpose   of   this   work,   the   midwifery   workforce   under   assessment   may   include   for   example   midwives,   gynaecologists,   neonatologists,   doctors,   nurses,   auxiliary   staff,   community   health   workers,   or   support   workers,   which   can   be   employed   by   different   types   of   facilities   or   organizations,   such   as   the   government,   a   private   health   care   provider,   or   a   non-­‐governmental   organization  (NGO).  In  some  countries,  e.g.  Bangladesh,  this  is  referred  to  as  the  MNH  workforce.  

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

2

Background  

In   September   2010   the   United   Nations   Secretary-­‐General   launched   the   Global   Strategy   for   Women’s  and  Children’s  Health.  As  part  of  their  broader  responses,  the  UN  health  agencies  -­‐   “H4+”  (UNAIDS,  UNFPA,  UNICEF,  World  Bank,  WHO)  -­‐  collectively  supported  countries  in  re-­‐ defining  their  commitments  to  MDG  4&5,  many  of  which  were  related  to  human  resources   strengthening.   The   H4+   proposed   to   support   a   select   set   of   countries   with   some   of   the   highest   burdens   of   maternal   and   neonatal   mortality   and   morbidity   (High   Burden   Countries   Initiative)  to  strengthen  implementation  of  key  maternal  and  neonatal  health  interventions.       Eight   countries   (Afghanistan,   Bangladesh,   Democratic   Republic   of   Congo,   Ethiopia,   India,   Mozambique,   Nigeria   and   United   Republic   of   Tanzania),   representing   nearly   60%   of   the   global   burden   of   maternal   and   newborn   deaths,   have   welcomed   the   response   of   the   H4+   and  are  in  continuing  discussions  to  enable  coordinated  actions  at  country  level.       On   September   18-­‐19,   2011,   the   H4+   and   the   International   Women’s   Health   Coalition   co-­‐ sponsored  a  high  level  meeting  hosted  by  the  Greentree  Foundation.  The  meeting  convened   key  actors  who  can  accelerate  progress  on  maternal  and  neonatal  health;  two  aspects  of  the   Millennium   Development   Goals   that   are   the   furthest   behind.   Participants   included   Health   Ministers   and   senior   health   officials   from   seven   of   the   eight   countries;   leaders   of   UN   agencies;   representatives   of   the   UN   Secretary-­‐General’s   MDG   Advocates   Group   and   civil   society,  the  private  sector,  partner  governments  and  health  professionals.  In  preparation  for   the   meeting,   reviews   were   conducted   of   the   available   information   on   all   aspects   of   the   human   resources   for   maternal   and   newborn   health   (MNH),   from   policies   to   regulations,   from   training   to   management   issues.   These   confirmed   piecemeal   knowledge   and   a   critical   lack   of   information   hampering   efficient   planning   and   programming   to   improve   access   to   skilled  care.       The   Greentree   meeting   concluded   that   the   H4+   would,   alongside   the   government   and   partners,   conduct   a   comprehensive   national   assessment   that   would   explore   the   most   challenging   issue   facing   maternal   and   neonatal   health:   human   resources   for   health   with   midwifery   competencies   at   the   community   level   (i.e.   midwives,   nurse-­‐midwives   and   community  health  cadres).       The  goal  of  this  assessment  is  to  provide  the  ministry  of  health  in  the  high  burden  country   with   an   analysis   of   the   existing   human   resources   for   MNH.   It   will   provide   the   ministry   of   health   with   costed   policy   options   addressing   the   midwifery   workforce,   aligned   with   the   national   health   strategy   and   plan,   and   national   HRH   and   MNH   strategies   and   plans   if   available.   The   aim   is   to   support   countries   to   reach   universal   access   to   skilled   assistance   during  pregnancy  and  childbirth.   2.1 Implementing  partners   UNFPA,   on   behalf   of   the   H4+,   has   taken   the   lead   role   in   responding   to   the   invitation   from   Ministers   of   Health   to   rapidly   develop   and   support   national   assessments   in   the   eight   countries.    A  Technical  Working  Group  (TWG)  was  established  in  November  2011.  The  TWG   comprises   UNFPA,   WHO,   UNICEF,   UNAIDS,   Global   Health   Workforce   Alliance   (GHWA),   ICS   Integrare,   Jhpiego,   the   Royal   Tropical   Institute   (KIT)   and   the   University   of   Southampton.   FIGO  and  ICM  are  recent  additions  to  the  TWG.  ICS  Integrare  functions  as  the  Secretariat  to   the  TWG.    

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

2.2 Planning,  objectives,  output   In  the  period  November  2011  –  March  2012  the  TWG  developed  an  assessment  framework   and   operational   guidance   to   support   the   national   activities.   These   were   tested   in   Ethiopia   in   February  2012.       This  final  version  will  now  guide  the  national  assessments  in  the  period  starting  from  March   2012.   The   objective   of   the   national   assessment   is   to   analyze   the   midwifery   workforce   at   the   community  level,  specifically  the  MNH  service  provision;  the  performance  of  the  midwifery   workforce;   work   environment;   management   and   policies;   and   financing   of   the   HRH   providing  MNH  services.  Data  will  be  collected  on  formal  policies,  guidelines  and  regulations,   as   well   as   on   the   current   situation   at   the   service   provision   level   and   on   promising   or   innovative  practices.     The   output   per   country   is   a   national   report   presenting   the   situation,   promising   practices,   and   costed   policy   options,   contributing   towards   the   goal   of   enhancing   the   quality   of   and   access   to   the   midwifery   workforce   at   the   community   level.   It   is   anticipated   that   country   reports  will  be  of  immediate  value  to  national  stakeholders  in  enabling  and  informing  their   national   strategies,   targets   and   commitments   to   improve   health   and   to   their   engagement   with   the   Every   Women,   Every   Child   campaign.   Each   country   will   determine   the   production   date  of  their  report.     A   progress   report   will   be   presented   during   the   Every   Woman   Every   Child   Summit   in   New   York   in   September   2012.   A   synthesis   report   of   key   findings,   lessons   learned   and   recommendations  from  the  country  reports,  is  anticipated  to  be  available  in  early  2013.       The  national  and  progress  reports  are  intended  to  support  two  objectives:       1. to   plan   effectively   for   HR   for   MNH   at   national   and   sub-­‐national   levels   in   the   high   burden  countries;  and     2. to   enable   evidence-­‐based   advocacy   for   domestic   and   international   resources   mobilization  to  support  implementation  of  the  national  strategy.    

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

3

Process  of  the  National  Assessment  

The   implementation   process   for   the   national   assessments   comprises   of   three   phases:   1)   preparation   and   country   engagement;   2)   national   assessments   and   reporting;   and   3)   synthesis.    Table  1  below  provides  an  overview  of  the  phases,  activities  and  outputs.  This  will   be  adapted  to  the  specific  context  of  each  of  the  eight  countries.     Level  

Activities  

International  and  national    

1.

Preparation  and  country  engagement  

Phase  

3.   Synthesis  

2.   National  assessments  and   reporting  

International   National  and  subnational  

Outputs  

1.  Document  review   2.Identification  of  representatives   from  MoH  and  H4+   3.  Scoping  mission   a.  Engaging  national  stakeholders   b.  Identification  of  on-­‐going  activities   (‘landscape  analysis’)   c.  Identification  of  in-­‐country  partner   d.  Review  and  refinement  of   assessment  framework     e.  Validation  of  data  collected  through   the  document  review   f.  Identification  of  knowledge  gaps   and  additional  data  sources   g.  Planning  of,  and  agreement  on,  in-­‐ country  data  collection  and  analysis.     h.  Exploration  and  development  of   options  on  the  reporting  structure.   i.  Agreement  on  roles  and   responsibilities  (scope  of  work)  of  the   government,  H4+  and  in-­‐country   assessment  partner(s).     1.  Commissioning  of  in-­‐country   partner   2.  In-­‐country  data  collection  

Background  paper   containing  the  contextual,   stakeholders  and   landscape  analysis     Partially  completed   assessment  framework     Scoping  mission  Back  to   Office  Report    

In-­‐country  partner   commissioned   Assessment  framework   completed  

3.  Data  analysis  

National  and  international    

4.  National  stakeholder  workshop  to   develop,  choose  and  test  scenarios   and  strategies   5.  Costing  analysis  and  testing   6.  Draft  report  and  testing     7.  Final  reporting   1.  Synthesise  key  findings,  lessons   learned  and  recommendations  from   country  reports  

International  

National  reports  with   costed  policy  options  

Synthesis  report  

Table  1:  National  Assessment  of  the  Midwifery  Workforce  at  the  Community  Level  –  process  overview  

3.1  Preparation  and  Country  Engagement  –  Phase  1   The   objectives   of   the   preparation   phase   are   to   gather   the   available   data   on   the   country   context   and   the   areas   of   the   assessment   framework,   as   well   as   to   identify   and   engage   representatives   of   the   Ministry   of   Health,   the   H4+,   possible   in-­‐country   partners   and   other   relevant   national   stakeholders.   The   anticipated   outputs   are   a   country   background   paper,   including   a   mapping   of   relevant   stakeholders,   a   partial   completion   of   the   assessment   framework,   and   a   report   of   the   scoping   mission.   The   collected   data   serves   as   an   information   base  that  can  be  validated  during  the  scoping  mission  and  will  be  further  improved  during  

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

the  in-­‐country  data  collection.  Throughout   phase   1   the   Secretariat   provides   support   through   the   H4+   representative  in   the   country   and   through   email,   Skype   or   telephone   (Help   Desk).   Phase   1   will   include   the   activities   described   below.   A   glossary   of   the   terms   used   for   the   assessment  process  can  be  found  in  Annex  A.     3.1.1 Document  review     It   is   anticipated   that   a   lot   of   data   and   information   is   already   available   in   the   grey   and   published   literature,   or   within   the   country.   This   information   will   be   identified   during   the   document   review   at   international   level,  during   which   publicly   available   documentation   will   be  collected,  summarized  and  analysed,  based  on  the  questions  and  indicators  formulated  in   the  assessment  framework.  Based  on  a  review  of  publicly  available  documents,  a  specified   request  for  additional  (unpublished)  information  can  be  made  well  in  advance  of  the  scoping   mission.   This   will   enable   development   of   a   background   paper   as   complete   as   possible   to   inform   the   mission   team   before   the   scoping   mission.   Annex   C   provides   a   list   of   possible   sources   of   information   for   the   document   review.   In-­‐country   H4+   and   other   TWG   partners   can  provide  support  in  identifying  and  acquiring  the  available  documentation.   3.1.2 Identification  of  representatives  from  the  Ministry  of  Health  and  the  H4+   UNFPA  and  WHO  will,  on  behalf  of  the  H4+,  engage  with  the  MoH  and  the  country  offices  of   the   H4+.   Representatives   from   the   MoH   (e.g.   the   Director   of   the   department   for   HRH,   nursing   or   midwifery)   and   the   H4+   country   offices   will   be   confirmed   as   focal   points   in   the   country.  Subsequently,  they  will  liaise  with  the  Secretariat  and  TWG  to  plan  and  coordinate   the  national  assessment.   3.1.3 Scoping  mission   a. Engaging  national  stakeholders   During  a  scoping  mission  of  the  assessment  team,  meetings  with  the  Ministry   of   Health   and   other   stakeholders   will   be   convened   to   introduce   the   process   and  content  of  the  national  assessment,  and  to  discuss  the  issues  listed  below.   It   is   recommended   to   involve   stakeholders’   communication   officers   to   raise   broader  awareness  of  the  national  assessment.     b. Identification  of  on-­‐going  activities   As   part   of   the   document   review   a   ‘landscape   analysis’   has   been   made   to   identify   on-­‐going   activities   related   to   the   midwifery   workforce,   such   as   research,   (pilot)   projects   etc.   This   landscape   analysis   will   be   validated   and   completed.   c. Identification  of  in-­‐country  partner   Jhpiego  will  provide  in-­‐country  support  in  the  seven  countries  where  they  are   present   through   their   country   offices   and   programs   (in   Afghanistan,   Bangladesh,   Ethiopia,   India,   Mozambique,   Nigeria   and   Tanzania).   This   includes   enabling   the   national   assessments   through   technical   and   logistical   support   and   also   acting   as   the   in-­‐country   research   partner   where   technical   capacity   exists.   The   Secretariat,   together   with   the   national   assessment   partners,   may   choose  to  commission  an  additional  institute  to  collaborate  with  the  national   assessment   partners   throughout   the   process   of   the   in-­‐country   data   collection.   The   in-­‐country   partners   will   be   involved   in   the   work  from   the   earliest   possible   stage,  to  allow  for  adequate  participation,  preparation  and  planning.     d. Review  and  refinement  of  assessment  framework,  with  country  stakeholders.   e. Validation  of  secondary  data  review   f. Identification  of  knowledge  gaps  and  additional  data  sources   Based  on  the  document  review  and  discussions  with  stakeholders,  knowledge   gaps   can   be   identified   against   the   domain   questions   and   indicators   in   the  

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

(refined)  assessment  framework.  Additional  in-­‐country  sources  of  information   will  be  identified  to  address  these  gaps.   g. Planning  of,  and  agreement  on,  in-­‐country  data  collection  and  analysis.     Remaining   knowledge   gaps   will   be   prioritized   with   stakeholders,   after   which   in-­‐country   data   collection,   and   analysis   will   be   discussed.   This   may   include:   exploration   and   development   of   options   on   the   methodology:   the   selection   of   data   collection   sites   and   key   informants;   the   tools;   and   the   approach   to   conduct   the   in-­‐country   data   collection;   development   of   a   schedule   of   activities;   process   of   identification   of   costed   policy   options;   and   dissemination   of  results.   h. Exploration  and  development  of  options  on  the  reporting  structure.   i. Agreement  on  roles  and  responsibilities  (scope  of  work)  of  the  government,  H4+  and   in-­‐country  assessment  partner(s).   This   will   include   responsibilities   related   to   national   and   international   communication  strategies.     The  scoping  mission  will  be  coordinated  by  UNFPA  (New  York)  on  behalf  of  the  H4+  and  the   TWG,  and  supported  by  the  Secretariat.  The  H4+  agencies  will  provide  in-­‐country  support,  in   close   collaboration   with   Jhpiego   as   the   in-­‐country   partner   in   seven   out   of   the   eight   countries.   A   summary   mission   report   will   be   made   available   to   the   TWG   after   the   scoping   mission.  The  duration  of  Phase  1  will  be  approximately  one  month.   3.2 National  assessment  –  Phase  2     Phase  2  starts  after  the  scope  of  the  country-­‐level  data  collection  has  been  established  and   once   in-­‐country   partners   are   identified.   It   is   foreseen   that   Phase   2   will   start   within   one   month  of    the   scoping   mission   and   will   take   10   weeks   from   start   to   finish.   Throughout   phase   2   the   Secretariat   provides   support   through   the   H4+   representatives   in   the   country   and   through  email,  Skype  or  telephone  (Help  Desk).       During  Phase  2,  the  national  assessment  team  will  be  working  closely  together  in  collecting   and  analysing  the  data  and  developing  scenarios  and  costed  policy  options.  The  assessment   framework  that  will  guide  the  national  assessment  is  discussed  in  Chapter  4.       Annex  D  provides  the  details  of  the  data  collection  during  the  national  assessment.  This  will   be   an   interactive   process,   and   will   include   a   stakeholder   workshop   to   engage   national   stakeholders  to  test  and  retest  proposed  policy  options.       The  anticipated  output  of  Phase  2  is  a  national  report,  owned  by  both  the  Ministry  of  Health   and  the  H4+,  on  the  midwifery  workforce  at  the  community  level,  and  which  includes  costed   policy  options,  that  will  enable  the  government  to  implement  a  costed  national  strategy.       3.3 Synthesis  –  Phase  3   A  brief  synthesis  report,  containing  key  findings  and  lessons  learned  from  the  eight  country   reports   will   be   developed   for   the   global   level   to   enable   evidence-­‐based   resource   mobilization.   It   will   provide   an   overview   of   the   options   in   the   national   reports   and   the   context  within  which  these  are  likely  to  be  successful.  It   will  also  identify  additional  activities   to   support   implementation   within   the   countries   or   to   address   continuing   knowledge   gaps.   This  report  is  expected  to  be  available  in  early  2013.  

April  2012.    

 

 

 

 

 

 

 

 

 

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

4

The  National  Assessment  Framework  

The   aim   of   the   national   assessment   is   to   answer   the   following   central   question   at   country   level:     'What  is  the  appropriate  midwifery  workforce,  and  how  is  it  best  deployed,  to  equitably   deliver  essential  MNH  interventions  at  scale  and  quality,  and  what  (including  costs)  needs  to   be  put  into  place  to  achieve  universal  access?'     In  order  to  answer  this  question,  the  assessment  will  address  the  following:   (i) describe   existing   policies,   guidelines   and   regulations   regarding   the   midwifery   workforce   and   identify   opportunities   to   improve   the   performance   (availability,   competencies,  responsiveness,  and  productivity)†  of  the  midwifery  workforce;   (ii) describe  the  current  performance  of  the  midwifery  workforce  as  well  as  factors   influencing   this   (education,   working   environment,   management,   policies   and   financing),   and   to   identify   gaps   and   opportunities   to   improve   universal   access   to   a  qualified  midwifery  workforce;   (iii) identify   promising   practices   aiming   to   improve   the   performance   of   the   midwifery  workforce  and  contributing  to  universal  access  to  MNH  services;   (iv) formulate   scenarios   and   costed   policy   options   addressing   the   midwifery   workforce   to   improve   quality,   equitable   access,   efficiency   and   utilization   of   midwifery  services  at  the  community  level.     The   operational   definitions   are   provided   for   guidance   in   Annex   A,   but   are   flexible   for   adaptation   to   the   national   context.   In   order   to   answer   the   central   question   and   the   component,  the  assessment  framework  considers  five  domains  of  investigation:     A. Essential  interventions  for  MNH  and  Utilization.  This  domain  relates  to  the  access,   equity,  quality,  efficiency  and  utilization  of  MNH  services.   B. Midwifery  workforce.  This  domain  relates  to  the  production  and  performance  of  the   midwifery   workforce.   This   includes   pre-­‐service   education   and   in-­‐service   training   capacities  in  the  public  and  private  sectors  and  the  availability  (including  distribution   and  attrition),  competencies,  responsiveness  and  productivity  of  health  workers.   C. Work   environment.   This   domain   relates   to   the   enabling   working   environment   to   maximise  and  sustain  the  midwifery  workforce’s  contribution  to  MNH.   D. Management  and  policies.  This  domain  relates  to  the  management  system  and  the   policies,   leadership   and   partnerships   to   maximise   and   sustain   the   midwifery   workforce’s  contribution  to  MNH.   E. Financing.   This   domain   relates   to   the   financial   resources   for   providing   adequate   financial   incentives   and   developing   costed   plans   to   maximise   and   sustain   the   midwifery  workforce’s  contribution  to  MNH.     A   set   of   questions   has   been   defined   to   guide   the   secondary   and   primary   data   collection   process  in  each  domain.  These  are  presented  in  Box  1  below.  In  addition,  a  set  of  indicators   has   been   suggested   per   domain.   The   questions   and   indicators   are   meant   to   guide   the   collection   of   both   quantitative   and   qualitative   data.   This   data   will   be   gathered   from   the   document  review  and  the  in-­‐country  data  collection,  from  both  the  national  and  subnational   level.   More   detailed   information   about   the   assessment   framework   (the   questions,   indicators,  and  the  assessment  tool)  can  be  found  in  Annex  B.      

 Based  on  the  WHO  framework  for  health  workforce  performance  as  formulated  in  the  World  Health  Report  2006,  p.71.  

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

                                                                                           

A.  Essential  Interventions  for  MNH  and  Utilisation   A1.  What  are  the  main  causes  of  morbidity  and  mortality  for  MNH  disaggregated  to  states/   regions/  districts  (the  lowest  level  available)?   A2.  What  are  the  associated  factors  with  the  four  most  common  causes  of  morbidity  and   mortality  and  are   these  similar  when  disaggregated  to  states/  regions/  districts   (the  lowest   level  available)?   A3.   Are   all   the   Essential   Interventions   for   MNH   (PMNCH   et   al.,   2011*)   part   of   current   health  services?   A4.   Which   health   workers   are   engaged   in   the   provision  of   the   Essential   Interventions  for   MNH  at  sub-­‐national  levels?     B.  Midwifery  workforce   B1.  What  is  the  availability  (composition,  distribution,  attrition)  of  the  midwifery  workforce   and  what  proportion  of  their  time  is  spent  delivering  the  Essential  Interventions  for  MNH?     B2.   What   is   the   current   (and   projected)   supply   of   the   midwifery   workforce   and   their   anticipated  d eployment?       B3.   What   are   the   competencies   of   the   midwifery   workforce   in   relation   to   the   Essential   Interventions  for  MNH?   B4.   What   is   the   quality   of   care   delivered   by   the   midwifery   workforce,   including   responsiveness?       C.  Work  Environment   C1.  Are  health  facilities  resourced  and  equipped  to  provide  the  Essential  Interventions  for   MNH?   C2.  Does  the  distribution  of  health  (BEmOC,  CEmOC  and  other)    facilities  correspond  with   population   needs/demands   at   the   level   of   states/   regions/   district   (the   lowest   level   available)?   C3.   What   is   the   functionality   of   existing   structures   and   processes   s   to   enable   successful   referral  (e.g.  transport,  inter-­‐collegial  collaboration  and  communications)?   C4.  What  is  the  model  of  care  at  birth,  including  composition,  roles  and  engagement  of  the   team  of  support  workers?   D.  M anagement   D1.   What   is   the   functionality   of   current   policies,   regulations,   M&E   and   accountability   mechanisms   to   manage   the   education,   training,   deployment,   performance   and   retention   of  the  midwifery  workforce?       D2.   What   is   the   functionality   of   health   and   HRH   information   systems   to   support   management  of  the  midwifery  workforce  and  deliver  the  Essential  Interventions  for  M NH?   D3.   What   is   the   coherence   and   functionality   of   policies,   strategies,   plans,   regulations   on   MNH  and  HRH?       D4.  What  are  the  governance  and  accountability  mechanisms  for  MNH  policy  making  and   implementation?   E.  Financing   E1.  What  is  the  current  and  projected  expenditure  on  the  midwifery  workforce?   E2.  Does  current  and  projected  expenditure  on  the  midwifery  workforce  relate  to  universal   coverage  of  the  Essential  Interventions  for  MNH?       E3.  What  are  the  current  and  p rojected  unit  costs  to  develop  expenditure  scenarios  for  the   education,  training,  deployment  and  retention  of  the  midwifery  workforce?   E4.  What   are  the  budgetary  and   fiscal   mechanisms  to  allocate  the  necessary  resources   for     an  appropriate  midwifery  workforce?         *  http://www.who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_summarytable.pdf       Box  1:  Overview  of  the  assessment  framework.  

April  2012.    

 

 

 

 

 

 

 

 

 

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

4.1 In-­‐country  data  collection   It   is   anticipated   that   the   data   from   the   document   review   will   not   suffice   to   complete   the   assessment  framework.  In-­‐country  data  will  therefore  be  collected  and  collated  with  the  aim   to   address   the   information   gaps   in   the   respective   countries.   It   is   acknowledged   that   perhaps   not   all   information   gaps   can   be   addressed   through   the   collection   of   primary   data,   given   limitations   in   time   and   budget.   During   phase   1   (preparation/   country   engagement)   knowledge  gaps  will  be  identified  and  agreement  will  be  reached  with  national  partners  on   the   in-­‐country   data   to   collect   and   the   methods   and   tools   to   be   used.     This   exercise   may   continue  in  the  early  part  of  Phase  2  to  ensure  national  participation  and  consensus.    A  more   detailed  protocol  of  the  in-­‐country  data  collection  is  provided  in  Annex  D.   4.2 Assessment  tools   For   the   in-­‐country   data   collection,   a   set   of   existing   and   validated   data   collection   tools   has   been   compiled.   These   are   drawn   from   WHO,   UNFPA   and   other   sources   (Annex   B)   as   a   result   of   recommendations   and   suggestions   from   the   TWG.     .   Each   tool   has   been   reviewed   to   identify  its  potential  utility  in  the  national  assessment  process.    The  specific  content  of  the   individual   tools   has   subsequently   been   mapped   to   the   five   domains   in   the   assessment   framework  to  identify  which  tool  will  provide  what  data.       When   knowledge   gaps   are   identified   at   country   level   across   the   five   domains,   the   corresponding  data  collection  tool(s)  can   be  selected  to  assist  in  generating  the  data  to  fill   the   gap.   Knowledge   gaps   will   be   identified   in   discussions   with   the   national   stakeholders   during   the   scoping   mission.   Tools   will   be   selected   based   on   a)   the   knowledge   gap   and   b)   the   feasibility  of  implementation  during  the  national  assessment  period  (phase  2).    This  process   allows   for   the   maximum   flexibility   to   adapt   the   assessment   to   the   national   context,   while   minimizing  the  potential  for  duplication  in  data  collection  efforts  at  country  level.     4.3 Data  analysis  and  identification  of  scenarios  and  costed  policy  options   The  analysis  aims  to  answer  the  main  question  of  the  national  assessment:     'What  is  the  appropriate  midwifery  workforce,  and  how  is  it  best  deployed,  to  equitably   deliver  essential  MNH  interventions  at  scale  and  quality,  and  what  (including  costs)  needs  to   be  put  into  place  to  achieve  universal  access?'     The   analysis   will   take   place   using   a   layered   approach   building   on   the   domains   and   guiding   questions   to   create   modelled   scenarios   of   workforce   supply   and   demand.   It   will   allow   detailed  analysis  of  country  situations,  enhancing  tailor-­‐made  solutions  to  determine:     1. Where  is  the  population  living?   2. What   is   the   demographic   profile   of   the   population   and   what   are   potential   MNH   needs  from  a  demographic  perspective?   3. What   is   the   epidemiological   profile   for   MNH   and   what   are   the   main   drivers   of   maternal  and  neonatal  mortality  and  morbidity?   4. Where  are  health  facilities  providing  MNH  services  located?   5. Where  is  the  MNH  health  workforce  located  and  what  is  their  performance?   6. Does  the  disaggregated  distribution  of  MNH  HRH  and  their  performance  correspond   with   the   disaggregated   MNH   needs   and   main   drivers   of   MNH   morbidity   and   mortality?   7. What  strategies  can  be  used  to  scale  up,  make  better  use  of  the  skill-­‐mix,  or  skill  up   the  workforce?      

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

The   in-­‐country   partner(s),   national   assessment   team,   Secretariat   and   the   members   of   the   TWG   will   work   closely   together   in   the   analysis   of   the   data.   Available   evidence   and   costing   information   will   be   used   to   model   policy   options   and   estimate   resource   requirements   to   improve   access,   quality,   efficiency   and   utilization   MNH   services   at   the   community   level.   This   will  be  done  through  an  interactive  process.       A   stakeholder   consultation   workshop   will   be   convened   with   national   decision-­‐makers,   stakeholders,   and   the   H4+   to   examine   the   draft   scenarios   and   policy   options.   During   this   consultation,   strategies   will   be   selected,   tested   and   refined,   based   on   their   importance,   relevance,   feasibility   and   acceptability.   The   findings   from   the   consultation   meeting   will   inform  the  national  report.      

4.4 Reporting   The  anticipated  output  of  Phase  2  is  a  national  report,  supported  and  adopted  by  both  the   Ministry   of   Health   and   the   H4+,   on   the   midwifery   workforce   at   community   level   that   will   inform  the  costed  national  strategies  at  country  level.       The   format   for   the   national   assessment   reports   will   be   developed   to   enable   utility   to   national  policy  and  planning  processes.  This  will  include  a  focus  on  modelled  scenarios  and   options  that  are  based  on  national  and  international  data  and  evidence.       Where  feasible,  costings  will  be  developed  in  support  of  the  OneHealth  financial  modelling   tool  ‡.    

 

 Available  at:    http://www.internationalhealthpartnership.net/en/working_groups/working_group_on_costing  

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

5

Quality  assurance  and  dissemination  of  results  

The   testing   and   validation   of   the   assessment   framework   and   operational   guidance   took   place   in   Ethiopia   in   February   2012.   The   TWG   and   external   experts   have   subsequently   reviewed   it.   The   guidance   and   framework   allows   for   flexibility   and   adaption   to   meet   the   specific  context  in  the  country.  It  will  be  reviewed,  adapted  and  refined  during  the  scoping   mission   by   the   national   assessment   teams   as   required.   The   document   originals   are   in   English.   Translation   to   French   and   to   Portuguese   is   anticipated   for   DRC   and   Mozambique   respectively.       Teams  of  national  and  international  experts,  drawn  from  the  partner  organisations,  will  carry   out  the  national  assessments.  This  will  be  under  the  guidance  of  the  representatives  of  the   H4+   and   the   Ministry   of   Health,   and   with   the   support   from   the   Secretariat.   Subject   to   the   knowledge  gaps  identified,  the  in-­‐country  partner  will  include  appropriate  research  skills  to   cover  the  topic,  i.e.  clinical  skills  and  experience,  social  science,  epidemiology  and  statistics,   health   systems   research,   human   resources   for   health,   health   economics   and   financing   and   policy   research.   The   ToRs   for   the   national   assessment   partners   will   be   developed  during   and   after  the  scoping  mission  in  each  country.     It   will   be   important   for   the   national   assessment   team   to   establish   strong   links   with   the   offices   of   all   H4+   agencies,   including   the   World   Bank,   UNAIDS,   and   UNICEF.   During   the   assessment  there  will  be  regular  interaction  between  the  national  assessment  team,  ideally   through  a  weekly  meeting  of  a  working  group  or  steering  committee.  This  will  allow  for  the   exchange   of   experiences,   lessons   learned   and  review   of   outputs   to   maintain   quality   but   also   serve  to  provide  input  and  support  to  implementation.       It   is   anticipated   that   the   MoH   and   the   H4+   partners   will   develop   national   communication   strategies   to   share   the   results   of   the   assessment   with   national   policy   makers   and   stakeholders.   This   will   be   agreed   upon   and   planned   during   the   scoping   mission.   The   members  of  the  TWG  will,  through  internal  actions  and  collaboration,  ensure  the  use  of  the   results  in  subsequent  planning  for  HRH  and  MNH  to  actually  improve  policy  and  practice  at   national  levels.     A   regional   and   global   communication   strategy   will   be   developed   by   the   H4+   and   the   members  of  the  TWG  in  partnership  with  the  respective  Ministries  of  Health.  The  following   opportunities   may   be   used   to   share   the   results   of   the   HBCI   with   regional   and   global   stakeholders:   • ECSACON  triennial  meeting,  to  be  held  in  Mauritius  in  September  2012.         • ‘Strengthening   national   capacities   for   midwifery   and   obstetric   education   and   training’  to  be  held  in  Maputo  in  September  2012.     • ‘Every  Woman  Every  Child’  to  be  held  in  New  York  in  September  2012.   • ‘XX  FIGO  World  Congress  of  Gynaecology  and  Obstetrics’  to  be  held  in  Rome  on  4-­‐6   October  2012.     The  members  of  the  TWG,  with  the  in-­‐country  representatives,  will  ensure  alignment  of  the   international   and   national   communication   strategies,   and   the   wide   dissemination   of   the   findings,  recommendations  and  advocacy  messages.    

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

6

Selected  References  

The   State   of   World's   Midwifery   2011:   Delivering   Health,   Saving   Lives   ((UNFPA,   2011),   provided   new   information   and   data   gathered   from   58   countries   in   all   regions   of   the   world   that  informed  an  analysis  of  midwifery  services  and  issues  in  countries  where  the  needs  are   greatest.  As  a  follow-­‐up  to  this  study,  the  national  assessment  on  the  midwifery  workforce   at   the   community   level   focuses   on   the   situation   in   eight   countries   with   a   high   burden   of   maternal   and   newborn   mortality   in   order   to   inform   national   strategies.   The   national   assessment   is   aligned   with   existing   documents,   frameworks   and   tools,   including   both   national   policies,   plans,   strategies,   targets   and   commitments   and   international   reference   documents.  A  selection  of  these  international  documents  is  listed  below.     Bryce, J., Victora, C. G., Boerma, T., Peters, D. H., & Black, R. E. (2011). Evaluating the scale-up for maternal and child survival: a common framework. International Health, 3(3), 139-146. Royal Society of Tropical Medicine and Hygiene. doi:10.1016/j.inhe.2011.04.003 Crigler, L., Hill, K., Furth, R., & Bjerregaard, D. (2011). Community Health Worker Assessment and Improvement Matrix ( CHW AIM ): A Toolkit for Improving CHW Programs and Services. Health Care. Fullerton, J. T., Ph, D., Leshabari, S., Technical, H., & Project, A. (2010). Assessment of the Midwifery Pre-Service Training Activities of the ACCESS Project. Health (San Francisco). Retrieved from http://pdf.usaid.gov/pdf_docs/PDACQ479.pdf ICM. (2010). Global Standards for Midwifery Education. Education. Retrieved from http://www.unfpa.org/sowmy/resources/docs/standards/en/R427_ICM_2011_Global_ Standards_for_Midwifery_Education_2010_ENG.pdf ICM. (2011a). Essential Competencies for Basic Midwifery Practice 2010 (pp. 1-19). Retrieved from http://www.unfpa.org/sowmy/resources/docs/standards/en/R430_ICM_2011_Essenti al_Competencies_2010_ENG.pdf ICM. (2011b). Global Standards for Midwifery Regulation. Regulation, 1-24. Retrieved from http://www.unfpa.org/sowmy/resources/docs/standards/en/R429_ICM_2011_Global_ Standards_for_Midwifery_Regulation_2011_ENG.pdf ICM. (2011c). Member Association Capacity Assessment Tool (MACAT). Leadership. Retrieved from http://www.internationalmidwives.org/Portals/5/2011/Global Standards/MACAT ENG.pdf PMNCH, WHO, & Aga Khan University. (2011). Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health. Retrieved from http://www.who.int/pmnch/topics/part_publications/201112_essential_interventions/ en/index.html UNAIDS. (2011). Countdown to zero: GLOBAL PLAN TOWARDS THE ELIMINATION OF NEW HIV INFECTIONS AMONG CHILDREN BY 2015 AND KEEPING THEIR MOTHERS ALIVE. UNFPA. (2011). The State of the World’s Midwifery 2011: Delivering Health, Saving Lives. Workforce. Retrieved from http://www.unfpa.org/sowmy/report/home.html UNFPA, ICM, & WHO. (2006). Midwifery in the Community: Lessons Learned. 1st International Forum on Midwifery in the Community, 11-15 December 2006, Hammamet, Tunisia.

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World Health Organization. (2010a). Packages of Interventions for Family Planning, Safe Abortion Care, Maternal, Newborn and Child Health. Reproductive Health. Retrieved from http://www.who.int/maternal_child_adolescent/documents/fch_10_06/en/index.html World Health Organization. (2010b). Increasing access to health workers in remote and rural areas through improved retention. Sciences-New York.

World  Health  Organization/  GHWA.  Human  Resources  for  Health  (HRH)  Action  Framework.        Available  at:  http://www.capacityproject.org/framework/       World  Health  Organization  (2010).  Essential  care  packages  and  the  role  of  midwifery       competencies  across  the  continuum  of  care  (adapted  in  UNFPA,  2011,  p.5).     World  Health  Organization  (2009).  Data  Mapping  Template  on  Human  Resources  for  Health.    

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Annex  A.  Glossary  and  operational  definitions   Glossary  of  the  National  Assessment  Process     Assessment  framework      

Overview   of   the   areas   of   investigation,   assessment   questions,   indicators   and  assessment  tools  to  guide  the  secondary  and  primary  data  collection  

Assessment  tools    

A   set   of   data   collection   instruments   to   support   the   collection   of   quantitative   and   qualitative   data.   To   be   adapted   based   on   the   specific   requirements   and   knowledge   gaps   in   the   country   in   which   the   national   assessment  takes  place  

Promising  practices    

Existing   innovative   strategies   in   the   country,   at   organization-­‐,   local-­‐,   district-­‐   or   national   level,   aiming   at   improving   the   midwifery   workforce.   These  practices  can  be  used  to  inform  national  strategy  development.  

Indicators    

A  set  of  standardized  measures  to  inform  national  strategy  development.  

National   team  

assessment   The   representatives   from   the   Ministry   of   Health   and   the   H4+,   the   in-­‐ country   assessment   partners,   the   Secretariat   and   the   Technical   Working   Group.      

In-­‐country  partner  

Country-­‐level   collection  

National   organization   (or   consortium)   that   is   part   of   and   works   closely   with  the  national  assessment  team  in  coordination  and  implementation  of   the   data   collection,   the   analysis   and   the   reporting   of   the   national   assessment.     data   Collection  of  data  at  the  country  level,  from  unpublished  documents  (not   available   to   the   public,   such   as   drafts   or   documents   for   internal   use)   or   directly  from  the  source,  such  as  databases,  registers,  or  interviewees.    

Document  review    

Collection   of   data   that   has   already   been   presented   in   documents   and   articles  that  are  publically  available.    

Spot  check    

Field   visits   to   collect   primary   data   and   information   related   to   the   actual   situation  at  the  health  facility  and  community  level.    

Topic  guide  

Data   collection   instrument   in   the   assessment   tool   that   guides   interviews   and  group  discussions.  

   

  Operational  definitions  for  the  national  assessment  framework       Maternal  and  Newborn  Health   For  the  purpose  of  this  work  and  in  accordance  with  the  H4+  consensus,  MNH  is  defined  as  the  health   of   women   during   pregnancy,   labour,   childbirth   and   the   postpartum   period.   It   also   includes   the   health   and   survival   of   the   foetus   during   labour   and   of   the   newborn   within   the   first   few   hours   and   days,   a   period  during  which  the  newborn  is  mostly  taken  care  of  by  the  professional  birth  attendant  (and  in   privileged   circumstances   the   neonatologist).   This   operational   definition   differentiates   from   the   health   of  the  neonate,  spanning  the  period  from  birth  till  the  end  of  the  fourth  week  after  birth  (neonatal   health,   neonatal   mortality)   (UNFPA,   2011;   p.161).   MNH   is   part   of   the   complete   continuum   of   care   for   reproductive,   maternal   and   newborn   health.   This   continuum   of   care   and   corresponding   midwifery   competencies  are  graphically  shown  in  figure  1.     A  detailed  description  of  the  specific  MNH  essential  interventions  to  reduce  reproductive,  maternal,   newborn   and   child   mortality   and   promote   reproductive   health   along   this   continuum   of   care   can   be   found  in  the  PMNCH  Essential  Interventions  Summary  (PMNCH,  WHO,  &  Aga  Khan  University,  2011;   p.4-­‐5).  

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

  “midwifery  workforce”   Health  care  workers  whose  primary  functions  include  health  care  to  women  in  reproductive  health,   pregnancy,  labour  and  birth  and  to  mothers  and  babies  in  the  postnatal  period  (UNFPA,  ICM,  &  WHO,   2006).   For   the   purpose   of   this   work,   the   midwifery   workforce   under   assessment   may   include   for   example  midwives,  gynaecologists,  neonatologists,  doctors,  nurses,  auxiliary  staff,  community  health   workers,  or  support  workers.  They  can  be  employed  by  different  types  of  facilities  or  organizations,   such  as  the  government,  a  private  health  care  provider,  or  a  non-­‐governmental  organization  (NGO).   The   midwifery   workforce   under   assessment   can   be   at   work   at   the   community   level,   the   primary   health  care  level,  BEmONC  and  CEmONC  as  referral  site  for  the  community  level.  For  categorization  of   the   different   types   of   health   care   workers,   the   classification   of   health   personnel   as   defined   in   the   country  will  be  used  and  a  link  will  be  made  between  these  cadres  and  the  classifications  of  HRH  in   the  WHO  Data  Mapping  Template  on  HRH.     “support  workers”   Lay   healthcare   workers,   village   volunteers,   traditional   birth   attendants   and   others,   who   work   and   have   links   with   the   midwifery   workforce   and   play   an   important   role   in   supporting   women’s   and   newborns’   access   to   skilled   care   for   safe   pregnancy   and   childbirth   including   postnatal   and   newborn   health  care(UNFPA  et  al.,  2006).    

  “community  health  worker(CHW)”     A  health  worker  who  has  received  standardized  training,  has  a  defined  role  within  the  community  and   the   larger   health   system,   and   performs   a   set   of   essential   health   services   (specific   to   MNH   in   this   instance)   (adapted   from   Crigler,   Hill,   Furth,   &   Bjerregaard,   2011).   This   operational   definition   will   be   tested  on  a  country-­‐by-­‐country  basis.     “at  the  community  level”   Level   of   the   health   system,   closest   to   where   families   live   e.g,   health   post,   health   centre,   -­‐   be   it   government,   private,   NGO   -­‐   or   the   family   home;   from   the   community/home   to   the   first   level   of   referral  which  is  usually  BEmONC.  (UNFPA  et  al.  2006;PMNCH,  WHO&  Aga  Khan  University,  2011).    

   

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Annex  B.  Assessment  Framework  -­‐  overview   INTRODUCTION     This   paper   has   been   informed   by   the   outcomes   of   the   TWG   meeting   in   Geneva,   revisions   following   feedback   from   the   TWG,   and   testing   during   a   scoping   visit   to   Ethiopia   (February   2012),  and  a  Secretariat  meeting  in  March  2012.      

The   approach   to   data   collection   and   analysis   is   based   on   existing   evidence   and   conceptual   frameworks  from  the  WHO,  UNFPA,  ICM  and  GHWA  in  relation  to  the  essential  interventions   for   Maternal   and   Newborn   Health,   and   for   Human   Resources   for   Health.   The   data  collection   will   be   based   on   existing   tools   across   the   areas   of   interest.   Using   this   approach   minimises   the  potential  for  duplication  in  data  collection  efforts  at  country  level,  enables  flexibility  to   focus   on   the   key   areas   of   concern,   and   enables   faster   implementation   of   data   collection   and   subsequent  data  analysis  and  synthesis  into  policy  options  and  costings.       OVERVIEW  QUESTION  AND  DOMAINS     The  national  assessments  aim  to  answer  the  following  overarching  question:     'What  is  the  appropriate  midwifery  workforce,  and  how  is  it  best  deployed,  to  equitably   deliver  essential  MNH  interventions  at  scale  and  quality,  and  what  (including  costs)  needs  to   be  put  into  place  to  achieve  universal  access?'  

 

At   the   next   level,   five   domain   areas   were   identified   with   a   sub-­‐set   of   questions   (a   5   by   4   matrix)  to  summarise  the  key  questions  to  guide  the  national  assessment.  A  number  of  tools   and  contextual  information  have  been  identified  and  will  be  used  at  country  level  to  inform   the  national  assessment.  These  cover  the  five  domains  of:  essential  interventions,  midwifery   workforce,  work  environment,  management  and  policy,  and  financing.         Please   note   that   the   actual   tools   used   and   data   collection   will   be   informed   by   the   information   gaps   at   country   level   and   therefore   may   differ   across   the   HBCI   countries   (see   figure   below   for   an   overview   of   the   process).     It   is   noted   that   countries   differ   in   the   availability   of   comprehensive   information,   evaluation   and   reports   relevant   to   human   resources  for  health  (HRH)  for  maternal  and  newborn  health  system.  Where  additional  data   are  available,  these  will  be  included  on  a  country-­‐by-­‐country  basis.      A  core  set  of  Indicators   was  developed  to  inform  data  collection  and  presentation  to  ensure  standardization  across   HBCI   countries   and   they   are   mapped   to   the   five   domain   areas   and   are   to   be   presented   alongside  a  comprehensive  assessment  of  all  the  data  as  available  and  collected  at  country   level.       The   national   assessments   will   be   practical   and   pragmatic,   adapted   to   each   country,   yet   maintaining   the   core   ambition   to   add   value   through   the   collation   and   synthesis   of   all   available  evidence  and  intelligence.  Spot  checks  and  small  area  studies  will  be  undertaken  in   order  to  validate  or  supplement  the  official  data.  The  overarching  question  and  five  domains   will  form  the  basis  of  the  final  report  and  presentations.      

      Five  Domains  to  guide  the  national  assessments.    

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  Domain   A.   Essential   Interventions   for   MNH   and   Utilisation   –   equitable   and   effective   coverage     (Indicators:   6   identified   at   present   and     further   updates   to   be   made   (majority   published  or  secondary  data)  

B.     Midwifery   Workforce   –   appropriate   midwifery   workforce   in   quality,   distribution  and  scale     (Indicators:   13     and   majority   are   country   level   reports   or   primary   data   collection   with   sub-­‐indicators.   C.   Work   Environment   –   the   MNH   system   facilitating   quality   and   safe   delivery   of   the   essential   MNH   interventions     (Indicators:  6  and  majority  are   country   level   reports   or   primary   data   collection   with   sub-­‐indicators)     D.  Management  and  Policy    –   providing   the   overarching   system  for  an  appropriate  and   sustainable   midwifery   workforce     (Indicators:   16   and   this   will   be   through   a   mix   of   published,   secondary   and   primary   source)     E.   Financing   –   enabling   environment   for   financing   and   developing   costed   plans   for   a   sustainable   midwifery   workforce   (Indicators:   5   overall   indicators   with   sub-­‐ indicators)    

Main  Questions   A1.   What   are   the   main   causes   of   morbidity   and   mortality   for   MNH   disaggregated   to   states/   regions/   districts   (the   lowest   level   available)?   A2.   What   are   the   associated   factors   with   the   four   most   common   causes   of   morbidity   and   mortality   and   are   these   similar   when   disaggregated   to   states/   regions/   districts   (the   lowest   level   available)?   A3.  Are  all  the  Essential  Interventions  for  MNH  (PMNCH  et  al.,  2011)   part  of  current  health  services?   A4.   Which   health   workers   are   engaged   in   the   provision   of   the   Essential  Interventions  for  MNH  at  sub-­‐national  levels?   B1.   What   is   the   availability   (composition,   distribution,   attrition)   of   the  midwifery  workforce  and  what  proportion  of  their  time  is  spent   delivering  the  Essential  Interventions  for  MNH?     B2.   What   is   the   current   (and   projected)   supply   of   the   midwifery   workforce  and  their  anticipated  deployment?   B3.   What   are   the   competencies   of   the   midwifery   workforce   in   relation  to  the  Essential  Interventions  for  MNH?   B4.  What  is  the  quality  of  care  delivered  by  the  midwifery  workforce,   including  responsiveness?   C1.   Are   health   facilities   resourced   and   equipped   to   provide   the   Essential  Interventions  for  MNH?   C2.   Does   the   distribution   of   health   facilities   (BEmOC,   CEmOC   and   other)   correspond   with   population   needs/demands   at   the   level   of   states/  regions/  district  (the  lowest  level  available)?   C3.  What  is  the  functionality  of  existing  structures  and  processes  s  to   enable  successful  referral  (e.g.  transport,  inter-­‐collegial  collaboration   and  communications)?   C4.  What  is  the  model  of  care  at  birth,  including  composition,  roles   and  engagement  of  the  team  of  support  workers?   D1.   What   is   the   functionality   of   current   policies,   regulations,   M&E   and   accountability   mechanisms   to   manage   the   education,   training,   deployment,   performance   and   retention   of   the   midwifery   workforce?     D2.   What   is   the   functionality   of   health   and   HRH   information   systems   to  support  management  of  the  midwifery  workforce  and  deliver  the   Essential  Interventions  for  MNH?   D3.   What   is   the   coherence   and   functionality   of   policies,   strategies,   plans,  regulations  on  MNH  and  HRH?     D4.   What   are   the   governance   and   accountability   mechanisms   for   MNH  policy  making  and  implementation?   E1.  What  is  the  current  and  projected  expenditure  on  the  midwifery   workforce?   E2.   Does   current   and   projected   expenditure   on   the   midwifery   workforce  relate  to  universal  coverage  of  the  Essential  Interventions   for  MNH?     E3.   What   are   the   current   and   projected   unit   costs   to   develop   expenditure   scenarios   for   the   education,   training,   deployment   and   retention  of  the  midwifery  workforce?   E4.   What   are   the   budgetary   and   fiscal   mechanisms   to   allocate   the   necessary  resources  for  an  appropriate  midwifery  workforce?  

 

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INDICATORS  LIST   The   following   are   the   context   and   specific   indicators/questions   that   are   expected   to   be   readily  available   within  the  literature,  through  published  indicators,  reports,    data  collection   and  in  some  cases  validated  at  country  level.  Paragraph  4  provides  an  overview  of  some  of   the   tools   that   will   be   adapted   for   use   as   part   of   the   data   collection.   Context   indicators/questions   (Set   P)   have   been   included   to   provide   contextual   information   for   the   country  and  population  development  indicators  (quantitative  and  qualitative  information).     The  data  will  be  disaggregated  to  sub-­‐national  levels  (regions/districts/provinces)  and  wealth   quintiles   where   data   is   available.   Data   will   be   based   on   recent   data   based   on   3   years   to   ensure   that   the   data   reflects   the   current   situation   and   data   from   facilities   gathered   in   the   last   5   years   will   be   used   where   major   changes   have   not   taken   place.   We   will   qualify   the   numerators  and  denominators  from  the  data  sources.       ID1  

ID2  

Domain  

Indicators/Questions    

A  

1  

Contraceptive  prevalence  rate  (modern   methods,  urban/rural)  %  

A  

2  

A  

3  

A  

4  

A  

5  

A  

6  

A  

7  

A  

8  

B  

1  

Essential   Interventions   for   MNH  and  Utilisation   Essential   Interventions   for   MNH  and  Utilisation   Essential   Interventions   for   MNH  and  Utilisation   Essential   Interventions   for   MNH  and  Utilisation   Essential   Interventions   for   MNH  and  Utilisation   Essential   Interventions   for   MNH  and  Utilisation   Essential   Interventions   for   MNH  and  Utilisation   Essential   Interventions   for   MNH  and  Utilisation   Midwifery  workforce  

B  

2  

B  

3  

April  2012.    

Data   availability   Published   or   secondary  

Skilled  attendance  at  birth  (Urban/rural)  %  

Published   or   secondary  

Number  of  pregnant  women  tested  for  HIV    

Published   or   secondary  

Proportion  of  pregnant  women  living  with   HIV  and  proportion  of  HIV-­‐exposed  infants   receiving  ARVs  for  PMTCT     Proportion  of  women  for  whom  AMTSL  has   been  applied  at  their  last  birth?  

Published   or   secondary  

Primary   or   country   level   data   Proportion  of  mothers  proportion  of   Primary   or   newborns  with  essential  postnatal  check-­‐up   country   level   within  48  hours  of  birth   data   What  are  the  5  leading  causes  for  maternal   Primary   or   mortality  and  for  neonatal  mortality  at   country   level   national  and  sub-­‐national  level?   data   Delivery  in  facility  %  Urban  /rural  or  by   Primary   or   subnational  distribution  (MAP)   country   level   data   Density  per  1000  birth  of  health  professionals   Published   or   (Drs,  nurses  and  midwives)   secondary   Midwifery  workforce     Density  per  1000  population  of    health   Published   or   professionals  (Drs,  nurses  and  midwives)     secondary   Midwifery  workforce   Number  of  midwives,  nurse-­‐midwives,   Primary   or   medical  professionals,  auxiliary  midwives,   country   level   Community  Health  Workers    and  other  cadres   data   (stock)  attending  birth     (all  numbers  to  be  disaggregated  by  age,   gender  and  geographic  location,  and   public/private  where  available    -­‐  graphics)    

 

 

 

 

 

 

 

 

 

21  


H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

B  

4  

B  

5  

B  

6  

B  

7  

B  

8  

B  

9  

B  

10  

B  

11  

C  

1  

C  

2  

Work  Environment  

C  

3  

Work  Environment  

C  

4  

Work  Environment  

C  

5  

D  

1  

D  

2  

D  

3  

D  

4  

April  2012.    

Midwifery  workforce   Density  of  midwives,  nurse-­‐midwives,   medical  professionals,  auxiliary  midwives,   Community  Health  Workers    and  other  cadres   attending  birth  per  1000  births  (all  numbers   to  be  disaggregated  by  age,  gender  and   geographic  location,  and  public/private/other   where  available    -­‐  graphics)   Midwifery  workforce   Proportion  of  all  active  MNH  professionals   working  in  private  sector,  army  and  police     Midwifery  workforce   Variation  between  the  headcount  and  the  full   time  equivalent  contributing  to  births  for  all   cadres  (estimates)   Midwifery  workforce   Number  and  location  of  schools/training   institutions  for  the  midwifery  workforce     Midwifery  workforce   Size  of  current  student  cohorts  for  the  last  3   years  by  school/training  institution  for  the   midwifery  workforce   Midwifery  workforce   Number  of  new  graduates  in  the  last  3  years   per  school/training  institution  for  the   midwifery  workforce   Midwifery  workforce   Proportion  of  practical  training    (skills  lab  and   on  site)  overall  pre-­‐service  education  period   for  midwifery  workforce     Midwifery  workforce   Proportion  of  the  midwifery  workforce   completing  competency-­‐led    in-­‐service   training  in  the  last  year   Work  Environment   Number  of  EmONC  and  CEmONC  facilities  per   500,000  pop  (Mapping)   Proportion  of  facilities  doing  deliveries  that   are  located  within  2  hours  travel  time  (by   usual  transport)  of  a  higher  level  facility   Proportion  of  total  facilities  with  functioning   transport  

How  many  obstetric  complications  have  been   transferred  by  motorised  vehicle  to  the   higher  level  facility  in  the  last  year  as  a  %  of   all  obstetric  cases  (estimates)   Work  Environment   Proportion  of  facilities  doing  deliveries  that   have  access  to  a  functioning   telecommunication  network  -­‐  landline,   mobile  phone,  radio     Management   and   Has  the  national  HRH  plan  a  MNH  component   Policies   and/or  has  the  national  MNH  plan  a  HRH   component   Management   and   What  is  the  country  planning  cycle   Policies   Management   and   National  health  development  plan  has  a  MNH   Policies   component,  including  MNH  indicators     Management   and   Existence  and  practice  of  task-­‐shifting   Policies   (national  or  subnational  policy?)    

 

 

 

 

 

 

 

 

Primary   or   country   level   data  

Primary   or   country   level   data   Primary   or   country   level   data   Published   or   secondary    

 

Primary   country   data   Primary   country   data   Primary   country   data   Primary   country   data   Primary   country   data   Primary   country   data  

or   level   or   level   or   level   or   level   or   level   or   level  

Primary   or   country   level   data   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   and   primary  data    

 

22  


H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

D  

5  

Management   Policies  

and   Are  maternal  death  reviews  regularly   practised    

 

6  

 

D ��

7  

D  

8  

Management   Policies   Management   Policies  

Is  there  any  evidence  of  the  findings  of  the   death  reviews  being  used  for  improvement   and   Existence  of  cost  data  for  current  and   projected  MNH  workforce     and   Presence  of  Parliamentary  sub-­‐Committee  on   Reproductive  Health    and  related  activity  

D  

9  

Management   Policies  

and   Fee  exemption  strategy  for  MNH  services   (and  indications  of  implementation)  

D  

10  

Management   Policies  

D  

11  

Management   Policies  

D  

12  

Management   Policies  

and   Existence  of  an  active  national/local  MNH   Committee  (not  limited  to  MoH)  and  its   activities.     and   Are  there  policies  encouraging  recruitment  of   local,  minority,  and  ethnic  students  into   midwifery?       and   Deployment  systems  including  Incentives  for   postings  in  hard  to  reach  areas  

D  

13  

Management   Policies  

and   Active  supervision/management  of  midwifery   workforce  in  workplace  

D  

14  

Management   Policies  

D  

15  

Management   Policies  

E  

1  

Finance  

E  

2  

Finance  

E  

3  

Finance  

E  

4  

Finance  

E  

5  

Finance  

and   Is  there  a  plan  for  monitoring  and  evaluation   of  HRH  strategic  objectives  through  reports   and  is  data  collection    supported  by  an  HRH   Information  System   and   Are  there  policies  and  laws  governing  the   scope  and  practice  of  the  midwifery   workforce  (e.g  midwives  allowed  to  perform   MVA,  prescribe  misoprostol,  and  emergency   contraception     What  are  the  salary  scales  for  the  midwifery   workforce  what  are  any  additional   incentives/personal  emoluments?   What  are  the  salaries/incentives  compared  to   other  public  and  private  sector  (e.g.   teacher/private  hospital)     Is  there  a  National  Health  Account  and     RMNCH  (and  or  variant)  sub  account  and   what  percentage  of  the  total  NHP  does  it   make  up?   Cost  of  pre-­‐service  education  disaggregated   where  available  by  in-­‐service  training   including  fees  and  housing     System  level  unit  costs  that  need  to  be  taken   into  account  for  options  planning  for  skilling   up,  scaling  up,  or  skill  mix  for  costed   strategies  

Published   or   secondary   and   primary     Published   or   secondary   Primary   or   country   level   data   Primary   or   country   level   data   Primary   or   country   level   data   Primary   or   country   level   data   Primary   or   country   level   data   Primary   or   country   level   data   Primary   or   country   level   data   Primary   or   country   level   data  

Primary   or   country   level   data   Primary   or   country   level   data   Primary   or   country   level   data   Primary   or   country   level   data   Primary   or   country   level   data  

         

April  2012.    

 

 

 

 

 

 

 

 

 

23  


H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

These  indicators  will  draw  upon  country  and  UN  population  indicators     P   1   Population   Population  size  2010     Development  and   Context   P   2   Population   Population  projected  2025     Development  and   Context   P   3   Population   Youth:  %  less  than  15  yrs  (and  projections  to   Development  and   2025)  [need  by  gender?]   Context   P   4   Population   %  rural  in  2010  (and  projections  to  2025)   Development  and   Context   P   5   Population   TFR  (Urban/Rural)  (and  projections  to  2025)   Development  and   Context   P   6   Population   %   Caesarean   sections   Urban/rural   or   by   Development  and   subnational   distribution   (MAP)   (and   Context   projections  to  2025)   P   7   Population   N°  expected  births/yr  and  projected  to  2025   Development  and   Context   P   8   Population   Neonatal   mortality   ratio   (and   number   of   Development  and   deaths/yr)   Context   P   9   Population   Maternal   mortality   ratio   (and   number   of   Development  and   deaths  /yr)   Context   P   10   Population   Proportion   of   adults   tested   positive   for   Development  and   HIV(male/female)   Context   P   11   Population   Number  of  HIV-­‐related   deaths   among   women   Development  and   who  were  either  pregnant  or  gave  birth  in  the   Context   preceding  six  weeks  (from  UNAIDS)   P   12   Population   Median  age  at  marriage  (yrs)  -­‐  Urban/Rural   Development  and   Context   P   13   Population   Life  expectancy  at  birth  (M/F)   Development  and   Context   P   14   Population   GNI  per  capita  (US$)   Development  and   Context   P   15   Population   %  population  below  poverty  line   Development  and   Context   P   16   Population   Expenditure  per  capita  on  Health  (%  of  public   Development  and   and  %  of  private  expenditure  on  health)   Context   P   17   Population   Literacy  rate  (M/F)   Development  and   Context          

April  2012.    

 

 

 

 

 

 

 

 

Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary   Published   or   secondary  

 

24  


H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

TOOLS     The   tools   utilised   will   draw   on   existing,   validated   tools   and   methods.   Recommendations   and   suggestions  of  the  TWG  and  the  Secretariat,  combined  with  online  searches  have  identified  a   set   of   30   tools   that   have   potential   utility   in   the   national   assessments.       This   list   will   be   reviewed  and  adapted  on  a  continuing  basis  to  reflect  lessons  learned  and  to  meet  country   requirements.         The   indicators   and   main   questions   investigated   as   part   of   HBCI   have   been   identified   and   the   tools   have   been   reviewed   to   map   their   consistency   with   the   assessment   framework   and   compile   a   tool   set   that   may   be   utilised   at   country   level.   Subject   to   the   tool   these   can   be   implemented   by   the   Ministry   representatives,   in-­‐country   partner   and   where   feasible,   through  the  Country  Mission  Team.      A  list  of  potential  tools  is  provided  below.       Domain   ID   B.   Midwifery  2   workforce   3a       13   15   26  

Name   Crigler  -­‐  CHW  AIM   ICM  2011  -­‐  preservice  education  assessment   UNFPA  Education  &  Training  Capacity  Tool   HRH  Mapping  Tool   WHO  2005  Workforce  and  Training  Tools  

8/8a  

MCHIP  PPH_PEE  2010/11  -­‐  PPH  and  PE/E  Questionnaire  

TBC  

WHO  Country  Assessment  Tool  on  HRH  Information  System  (Draft)  

C.   Work   23   Environment    

Service   Availability   and   Readiness   Assessment   (SARA   –   WHO),   (where  EmONC  Report  is  not  up-­‐to-­‐date)  

D.  Management  and   1   Policies   3b    

Boerma  -­‐  health  system   ICM  2011  –  Associations  

3f  

ICM  2011  -­‐Midwifery  Regulation  Assessment  Tool  

25  

GHWA  HRH  National  Policy  Impact  Assessment  Tool  

30  

WHO   Country   Assessment   Tools   on   Human   Resources   for   Health   (HRH)  Information  Systems:  Sources  and  uses  of  HRH  data  

E.  Finance    

27  

RH  Costing  2011  

28  

One  Health  Tool/Spectrum  

All  domains    

6  

KIT  MNH  -­‐  A  tool  for  planning  and  management  of  HRH  2010  with   adjustments   and   additions   based   on   country-­‐specific   issues   and   gaps  identified.    

 

April  2012.    

 

 

 

 

 

 

 

 

 

25  


H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

Annex  C.  Suggested  sources  for  document  review   •

• • • •

National  Health/  MNH/  HIV/  HRH  policies,  strategies,  plans,  (evaluation)  reports,  and   surveys,   such   as   the   Demographic   and   Health   Survey,   HRH   census   report,   district   health   service   reports,   and   MNCH   services   evaluations.   Other   sources   may   be   unpublished   national   policies,   plans,   strategies   and   evaluations;   information   from   the  National  Health  Account;  the  National  Health  Management  Information  System;   the  National  Human  Resource  Information  System  and  the  national  payroll;  registers   from   professional   organizations   and   councils;   and   registers   from   training   institutions.   Reports   from   professionals   associations,   regulatory   organizations,   training   institutions  and  institutions  such  as  HRH  committees  or  task  forces  and  relevant  civil   society  organizations.   H4+  sources,  such  as:   o National   government   commitments   for   the   Every   Woman   Every   Child   Campaign   o WHO  country  profiles     http://www.who.int/countries/en/   o UNFPA  gap  analysis   o State  of  the  World  Midwifery  Report   http://www.unfpa.org/sowmy/report/home.html   o WHO  Service  Availability  Mapping  (SAM)   http://www.who.int/healthinfo/systems/samintro/en/index.html   o WHO  Service  Availability  and  Readiness  Assessment  (SARA)   http://www.who.int/healthinfo/systems/sara_introduction/en/index.html   o Countdown  to  2015  report,  2010  http://www.countdown2015mnch.org/   o UNICEF  Multiple  Indicator  Cluster  Survey  (MCIS).   o UNAIDS.   Countdown   to   zero:   Global   Plan   towards   the   elimination   of   new   HIV   infections   among   children   by   2015   and   keeping   their   mothers   alive   (UNAIDS,  2011).   o UN  Commission  on  Commodities  for  Women’s  and  Children’s  Health.   o UNGASS  and  UNDAP  reports.   Reports   from   bilateral   donors,   NGOs,   global   health   projects   and   initiatives   (USAID,   JHPIEGO,  GHWA,  HRH  Global  Resource  Center)   Scientific  articles  from  e.g.  the  Human  Resources  for  Health  Journal   AfriPop   http://www.afripop.org/   EmONC  assessments     www.amddprogram.org  

 

April  2012.    

 

 

 

 

 

 

 

 

 

26  


H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

Annex  D.  Detailed  information  on  the  in-­‐country  data  collection  and  analysis   The   aim   of   the   in-­‐country   data   collection   is   to   complement   the   document   review   in   identifying   existing   situation,   policies   and   practices   (including   promising   practices)   related   to   the  availability  and  performance  of  the  midwifery  workforce,  and  more  specifically  the  five   areas  of  investigation:  essential  interventions  for  MNH  and  utilization,  midwifery  workforce   and  education,  work  environment,  management,  policies  and  financing.  Data  collection  can   take  place  at  national  level  and  subnational  level  (district  and  facilities/organizations).       This   data   collection   will   generate   perspectives   on   existing   policies   and   plans   and   allow   the   identification   of   promising   practices.   Spot   checks,   focus   groups   and   semi-­‐structured   interviews  may  be  used  e.g.  regarding  implementation  of  the  model  of  continuum  of  care;   activities   contributing   to   a   competent   and   motivated   midwifery   workforce;   and   responsiveness  to  needs  of  the  community.       Data   collection   sites   (organizations,   facilities,   institutions)   and   respondents   should   be   purposefully   selected   in   such   a   way   that   they   provide   rich,   in-­‐depth   information   from   different   perspectives   on   the   questions   at   hand.   The   in-­‐country   data   collection   does   not   intend   to   collect   data   that   represents   the   situation   across     the   whole   country.   This   means   that  the  sampling  would  need  to  be  purposeful,  focusing  on  recruitment  of  respondents  with   relevant  experience.  It  will  be    more  important  to  have  in-­‐depth  information  from  a  limited   number   of   people   at   national   and   subnational   level,   than   to   have   little   or   incomplete     information  from  a  large  group  of  people.       National  level     Primary   data   can   be   collected   at   the   national   level   through   data   extraction   from   existing   information   systems   or   interviews   or   group   discussions   with   (representatives   of)   government   departments,   public   and/or   private   organisations   involved   in   MNH   service   provision,  and  training  institutions.       At  national  level,  respondents  could  be,  for  example  :   •   Policy  makers;   •   HRH  committees  or  task  forces;   • Parliamentarians  or  civil  society  organizations;   • National  health  research  institutes;     •   National  H4+  offices;  national  donor  offices;  or  national  NGO  offices;   •   Umbrella  organizations  for  public,  private,  or  NGO  MNH  services  providers;   •   Professional  (association)  leaders;   § Representatives  from  midwifery  workforce  training  institutes.     Sub-­‐national  level:  spot  checks   In  addition,  one  or  two  ‘spot  checks’  can  be  conducted  at  the  level   of   districts   (e.g.   program   managers   or   district   health   team   members)   and   at   health   care   facilities   or   organizations   where   the   practising   midwifery   workforce   is   employed.   The   aim   of   the   spot   checks   is   to   collect  data  that  provides  an  indication  of  the  situation  ‘on  the  ground’  in  a  specific  facility  or   with  a  specific  organization.  To  limit  the  scope  of  work  while  allowing  for  the  collection  of  in-­‐ depth  information,  it  is  suggested  to  select  a  maximum  of  two  districts  and  2-­‐3  facilities  per   district.  This  needs  to  be  decided  with  the  national  partners.     Sampling   needs   to   be   done   purposefully   to   allow   for   the   collection   of   rich   and   in-­‐depth   information  from  a  wide  variety  of  situations.  The  selection  criteria  and  the  identification  of  

April  2012.    

 

 

 

 

 

 

 

 

 

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

relevant   regions,   districts   and   facilities   should   be   jointly   formulated   with   the   national   partners.   For   example,   selection   criteria   could   include   selecting   districts   with   different   or   contrasting   characteristics   such   as   an   urban   and   rural   district   ;   or   a   well-­‐performing   and   a   not-­‐so-­‐well  performing  district.       At   district   level,   different   stakeholders   (such   as   the   government,   or   non-­‐governmental   organizations)  can  be  involved  in  providing  MNH  services.  Interviews  could  be  held  with  the   following  respondents,  using  the  topic  guide  for  managers:   • Local  government  representatives;   • District  health  management  team  members;   • Maternal,  newborn  and  SRH  Program  officers;     Within   the   districts,   a   number   of   health   facilities   should   be   visited.   These   should   be   purposefully   selected   as   well,   e.g.   according   to   population   they   serve   or   their   affiliations,   such   as   a   facility   serving   mainly   minority-­‐,   nomadic-­‐,   or   sedentary   populations;   facilities   with   different   forms   of   ownership,   such   as   public,   private-­‐for-­‐profit,   and   not-­‐for   profit   facilities;   or  facilities  providing  outreach  services,  primary  care,  BEmONC  and  CEmONC.       Cadres   providing   midwifery   services   within   these   facilities   should   also   be     purposefully   selected,   according   to   cadre,   gender,   age,   or   other   characteristics.   A   maximum   of   about   five   respondents   per   cadre   will   allow   for   sufficient   in-­‐depth   information   per   facility,   and   assurance   needs   to   be   made   that   interviewing   stops   when   saturation   of   information   is   achieved   (i.e.   data   collection   stops   when   no   new   information   emerges-­‐this   can   be   already   after  3  interviews,  but  might  take  up  to  five).  Alternatively,  one  interview  could  be  replaced   by   a   group   discussion   with   cadres   of   the   same   level.   In   each   facility   that   is   visited,   it   is   suggested  to  interview  the  manager,  using  the  topic  guide  for  managers.  Data  and  sources   should   be   triangulated:   for   instance   interviews   with   managers   and   care   providers   at   primary   and   secondary   level   need   to   be   triangulated   with   each   other   and   compared   to   secondary   data  (including  information  from  national  information  systems  and  registers).       Depending   on   the   knowledge   available   and   identified   gaps,   data   can   be   collected   from   community  members,  in  order  to  gain  the  perspective  of  clients  on  the  provision  of  essential   MNH   services   and   the   midwifery   workforce.   A   subset   of   tools   is   available   from   the   Secretariat,   when   needed.   Decisions   on   the   collection   of   data   at   the   community   level   will   be   made  at  country  level  by  the  national  assessment  team.     For  each  interview,  consent  shall  be  asked  and  confidentiality  and  anonymity  of  respondents   assured.       Data  collection  techniques   The  following  techniques  can  be  used  to  collect  the  in-­‐country  data  to  address  the  identified   knowledge  gaps:   • Review  of  published  data  and  documents  from  previously  unidentified  sources   • Review  of  unpublished  documents,  records,  databases,  registers;   • Semi-­‐structured  interviews;   • Group  Discussions  (GD);   • Direct  observation   Examples  of  specific  data  collection  instruments  for  this  can  be  found  in  the  assessment  tool.   Per   country   a   selection   will   be   made   of   required   data   collection   tools   (given   the   identified   knowledge  gaps)  and  corresponding  data  collection  techniques.    

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Plan  for  data  collection   After   the   definition   of   data   gaps,   data   collection   sites   and   data   collection   methods   and   instruments,  the  fieldwork  has  to  be  planned  and  scheduled.    The  in-­‐country  partners  may   need  to  consider  and  respond  to  a  number  of  planning  questions,  including:     • What  is  the  focus  of  the  fieldwork,  ands  what  will  be  the  roles  and  responsibilities  of   the  in-­‐country  data  collection  team  members?     • What  material  and  logistical  support  is  needed?     • Is  the  plan  within  the  available  budget?     • Is  there  sufficient  time  planned  for  tool  translation,  pre-­‐testing  and  data  processing   (entering  data  in  data  base,  transcription  of  interviews  and  group  discussions)   • Is  there  permission  from  the  authorities  of  the  data  collection  sites  to  proceed?   • Are   facilities   and   organisations   informed   about   the   purpose,   data   requirements,   and   schedule  of  the  visit?   • How  do  we  enter  and  store  our  collected  data?     • How  do  we  assure  the  quality  of  collected  data?     Data  analysis   Data   storage   and   analysis   will   be   done   at   country   level   with   the   use   of   hardware   and   software   available   in   the   country.   Reporting   formats   will   be   developed   at   national   level.   Experiences,   examples  and  formats  available  from  other  HBCI  national  assessment  countries   can  be  used,  as  appropriate.  Throughout  phase  2  the  Secretariat  provides  support  through   the   H4+   national   focal   point   in   the   country   and   provides   support   through   email,   Skype   or   telephone   (Help   Desk).   The   in-­‐country   partner(s),   national   assessment   team,   Secretariat   and   the   members   of   the   TWG   will   work   closely   together   in   the   analysis   of   the   data.   Latest   evidence   and   adequate   costing   information   will   be   used   to   draft   costed   scenarios   and  policy   options  to  improve  access,  quality,  efficiency  and  utilization  MNH  services  at  the  community   level.   This   will   be   done   through   an   interactive   process.   Subsequently,   a   stakeholder   consultation   workshop   will   be   convened   with   national   decision-­‐makers,   stakeholders,   and   the   H4+   to   examine   the   draft   scenarios   and   policy   options.   During   this   consultation,   strategies  will  be  selected,  tested  and  refined,  based  on  their  urgency,  relevance,  feasibility   and  acceptability.  The  findings  from  the  consultation  meeting  will  inform  the  national  report.       Ethical  review   It   is   anticipated   that   data   collection   at   sub-­‐national   level   may   require   ethical   approval.   In   such   instances,   a   nominated   H4+   representative   will   coordinate   application   and   clearance   with   the   relevant   national   ethical   review   authorities   as   early   as   possible   in   the   process   of   engaging   with   the   country.   Most   Ethics   Review   Boards   ask   similar   information.   Annex   E   provides   an   overview   of   the   typical   information   requirements   and   can   be   adapted   as   per   requirements   in   each   country.   Given   Jhpiego’s   role   in   the   national   assessments,   there   will   additionally  be  ethics  review  clearance  from  Johns  Hopkins  University.     Quality  assurance  in-­‐country  data  collection   The  national  research  partner  is  responsible  for  following  national  guidelines  and  regulations   related   to   carrying   out   and   publishing   research.   It   should   be     assured   that   all   team   members   have   a   thorough   understanding   of   the   background   of   the   assessment   in   order   to   ensure   appropriate   in   depth   assessment   and   questioning.   Preferably,   the   interviews   and   group   discussions   should   be   taped   (after   permission   is   sought)   and   transcribed,   so   as   to   allow   completeness  in  reporting.  During  data  collection  and  before  data  processing  the  collected   data  should  be  checked  for  completeness  (in  comparison  to  the  assessment  framework)  and   internal  consistency  (in  comparison  to  earlier  data  collected).  When  data  is  inconsistent  or  

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missing,   either   additional   data   can   be   gathered,   or   data   should   be   excluded.   During   data   entry,  a  check  should  be  performed  to  ensure  accuracy  of  the  data  entered.     Regarding   the   extraction   of   data   from   (un)published   documents,   health   information   systems,   registers   and   databases,   the   in-­‐country   partner(s)   will   verify     that   the   source   contains  accurate,  complete  and  updated  information.  If  several  data  bases  are  available  on   the  same  topic  (e.g.  numbers  of  HRH)  a  decision  needs  to  be  made  jointly  with  the  national   representatives  on  the  most  appropriate  source  or  sources  to  use.     Regarding   the   interviews   and   group   discussions,   it   is   important   that   the   national   partner   translates   the   topic   guides   (if   required,   possibly   for   sub   national   level)   with   back   translation,   adapts   the   topic   guides   to   the   local   situation   and   pre-­‐test   these   before   data   collection   is   done.        

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 Annex  E.  Typical  information  for  Ethics  Review  Board.     Title   High   Burden   Countries   Initiative   National   Assessment   on   the   Midwifery   Workforce   at   the   Community  Level.     Background   The   information   in   Chapter   2   (‘Background   of   the   H4+   HBCI   National   Assessment   on   the   Midwifery  Workforce  at  the  Community  Level’)  can  be  copied  for  this  section.     Applying  organization   The  United  Nations  Population  Fund  (UNFPA),  on  behalf  of  the  H4+  (UNFPA,  WHO,  UNAIDS,   UNICEF,  World  Bank).     Principal  Investigator  (PI)   A  representative  of  either  the  H4+  or  in-­‐country  assessment  partners  (i.e.  Jhpiego)     Goals  and  objectives   The   goal   of   the   HBCI   National   Assessment   is   to   enhance   the   quality   of   and   access   to   the   midwifery  workforce  at  the  community  level.  It  is  anticipated  that  this  will  be  of  immediate   value   to   national   stakeholders   in   enabling   and   informing   their   national   strategies,   targets   and   commitments   to   improve   health.   The   objective   of   the   national   assessment   is   to   analyze   the   midwifery   workforce   at   the   community   level;   specifically   the   MNH   service   provision;   the   performance  of  the  midwifery  workforce;  work  environment;  management  and  policies;  and   financing   of   the   HRH   providing   MNH   services.   Data   will   be   collected   on   formal   policies,   guidelines  and  regulations,  as  well  as  on  the  current  situation  at  the  service  provision  level   and   on   promising   or   innovative   practices.   The   output   per   country   is   a   national   report,   presenting  the  situation,  promising  practices,  and  costed  policy  options,  with  the       More  specifically,  the  goal  of  the  data  collection  at  the  sub-­‐national  level  is  to  complement   the   document   review   in   identifying   existing   situation,   policies   and   practices   (including   promising   practices)   related   to   the   availability   and   performance   of   the   midwifery   workforce,   and   more   specifically   the   five   areas   of   investigation:   essential   interventions   for   MNH   and   utilization,   midwifery   workforce   and   education,   work   environment,   management,   policies   and   financing.   The   objective   of   the   data   collection   at   the   sub-­‐national   level   (district   and   facilities/organizations)    is  to  generate  perspectives  on  existing  policies  and  plans  and  allow   the   identification   of   promising   practices.   Spot   checks,   focus   groups   and   semi-­‐structured   interviews  may  be  used  e.g.  regarding  implementation  of  the  model  of  continuum  of  care;   activities   contributing   to   a   competent   and   motivated   midwifery   workforce;   and   responsiveness  to  needs  of  the  community.’     Research  protocol   j. Study  type   This  is  an  exploratory  assessment.     k. Research  question   The  central  question  of  the  national  assessment  is:   'What  is  the  appropriate  midwifery  workforce,  and  how  is  it  best  deployed,  to  equitably   deliver  essential  MNH  interventions  at  scale  and  quality,  and  what  (including  costs)  needs  to   be  put  into  place  to  achieve  universal  access?'    

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l. Concepts  and  variables   The  following  concepts  and  variable  form  the  basis  of  the  national  assessment:   (1) The  midwifery  workforce  at  the  community  level.     The  operational  definitions  used  are  described  Annex  A.   (A) Essential   interventions   for   MNH   and   Utilization.   This   domain   relates   to   the   access,   equity,  quality,  efficiency  and  utilization  of  MNH  services.   (B) Midwifery  workforce.  This  domain  relates  to  the  production  (including  pre-­‐  and  in-­‐ service   training   capacities   of   both   public   and   private   training   institutes),   performance   (availability   –   including   distribution   and   attrition   –,     competencies,   responsiveness  and  productivity)  of  the  midwifery  workforce.   (C) Work   environment.   This   domain   relates   to   the   enabling   working   environment   to   maximise  and  sustain  the  midwifery  workforce’s  contribution  to  MNH.   (D) Management  and  policies.  This  domain  relates  to  the  management  system  and  the   policies,   leadership   and   partnerships   to   maximise   and   sustain   the   midwifery   workforce’s  contribution  to  MNH.   (E) Financing.   This   domain   relates   to   the   financial   resources   for   providing   adequate   financial   incentives   and   developing   costed   plans   to   maximise   and   sustain   the   midwifery  workforce’s  contribution  to  MNH.     m. Data  collection  techniques   The   techniques   that   will   be   implemented   depend   on   the   knowledge   gaps   and   corresponding   data   collection   tools   identified.   In   case   e.g.   that   the   topic   guides   are   selected   for   data   collection,   the   corresponding   data   collection   techniques   are   semi-­‐structured   interviews   or   group  discussions.  When  (parts  of)  the  Service  Availability  and  Readiness  Assessment  (SARA)   tool  are  used,  the  data  collection  techniques  used  may  include  direct  observation.  For  each   county,  the  tools  selected  and  corresponding  data  collection  techniques  should  be  explained   here.     n. Sampling  and  recruitment  of  the  study  population   The   following   text   on   sampling   can   be   used   as   a   basis   for   this   text:   ‘Data   collection   sites   (organizations,   facilities,   institutions)   and   respondents   should   be   purposefully   selected   in   such   way   that   they   provide   rich,   in-­‐depth   information   from   different   perspectives   on   the   questions   at   hand.   The   in-­‐country   data   collection   does   not   intend   to   collect   data   that   represents  the  situation  in  the  whole  country.  This  means  that  the  sampling  would  need  to   be  purposeful,  focusing  on  recruitment  of  respondents  with  relevant  experience.  It  is  more   important   having   in-­‐depth   information   from   a   limited   number   of   people   at   national   and   subnational   level,   than   to   have   little   information   from   a   large   group   of   people.   ’   However,   this  needs  to  be  specified  on  the  basis  of  the  selection  criteria  that  have  been  agreed  upon   at  country  level.  For  example,  selection  criteria  could  include  selecting  districts  with  different   or   contrasting   characteristics   such   as   an   urban   and   rural   district   ;   or   a   well-­‐performing   and   a   not-­‐so-­‐well  performing  district.       § Data  collection   See  Annex  D  ‘National  level’;  ‘sub-­‐national  level:  spot-­‐checks’;  and  ‘quality  assurance  of  in-­‐ country  data  collection’.       § Data  analysis   The  text  on  analysis  and  data  processing  and  management  in  paragraph  4.3  (‘  Data  analysis   and  identification  of  scenarios  and  costed  policy  options’)  can  be  used  for  this  section,  but   has  to  be  specified  based  on  the  operationalization  of  the  in-­‐country  data  collection  that  has   been  agreed  upon.  

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  Letters  of  collaborating  organizations   Paragraph   2.1   (‘Implementing   partners’)   describes   the   organizations   involved   in   the   HBCI   national  assessments.  Any  additions  to  this  composition  within  a  specific  country  should  be   noted.       CVs  of  the  PI  and  relevant  senior  researchers   These  should  often  be  submitted  as  well  and  should  ideally  include  a  national  staff  member   of  the  H4+,  and  the  national  partners  (Jhpiego  +  others  as  appropriate)       Informed  consent  form   For  each  interview,  consent  shall  be  asked.  An  example  consent  form  in  English  can  be  found   in  below.  The  in-­‐country  assessment  partner  should  translate  the  consent  form  to  the  local   language  when  needed,  based  on  the  respondents  for  the  data  collection.      

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H4+  High  Burden  Countries  Initiative  (HBCI):  Operational  guidance  and  assessment  framework  

Informed  Consent  Form  for  Semi  Structured  Interview     Good   morning/afternoon.     My   name   is   ________.   I   am   a   researcher   working   with   __[research   institute]______   and   we   are   doing   a   study   on   the   health   workers   providing   health   care   to   women   during  pregnancy,  labour  and  birth  and  to  mothers  and  babies  in  the  postnatal  period.  This  study  is   part   of   a   wider   study   which   aims   at   describing   the   situation   in   eight   different   countries   and   is   implemented  by  the  Ministry  of  Health  in  collaboration  with  the  United  Nations  Populations  Fund,  the   World  Health  Organization,  the  World  Bank,  UNAIDS,  and  UNICEF.       Purpose  of  the   study:   The  aim   of   this   study  is  to  …  We  want  to  gather  evidence  regarding  …   and  want   to   find   out   ....   Through   this   study   we   want   to   contribute   to   future   policies   on   health   workers   for   health  care  to  mothers  and  children  before,  during  and  after  birth.    Therefore,  we  would  be  grateful  if   you   could   agree   to   share   your   thoughts   and   experience   regarding   this   topic.   (For   a   GD:   Therefore,   we   would   be   grateful   if   you   could   participate   in   a   group   discussion   to   share   your   thoughts   and   experience   regarding  this  topic).     Discomfort   and   risk:   The   questions   we   will   be   asking   about   your   ideas   regarding   the   midwifery   workforce   as   you   have   been   observing   them.   The   study   should   not   cause   any   harm   to   you   or   the   community.       Duration   of   participation:   The   interview   (for   GD:   discussion)   will   take   about   ….   Your   participation   is   voluntary  and  your  decision  on  whether  you  will  participate  or  not  in  this  study  and  the  answers  you   will  give  will  not  have  any  influence  on  how  you  will  be  treated  in  the  health  services  in  the  future  or   how   you   will   be   appraised   in   case   you   are   employed   in   the   health   system.   Nevertheless   if   you   feel   uncomfortable   with   certain   questions   you   can   decide   to   not   answer   these   and   you   can   stop   the   interview  at  any  moment  in  time.     Confidentiality:  The  interview  will  be  confidential  and  your  name  will  not  appear  in  the  report  but  will   only   be   recorded   on   the   consent   form.(For   GD:   You   should   be   aware   though   that   we   cannot   guarantee   full   confidentiality   on   your   contribution   in   the   group   discussion,   but   we   will   treat   discussion   as   confidential   and   want   to   ask   you   to   do   the   same   regarding   things   the   other   group   members   will   be   saying.  Your  name  will  be  recorded  on  the  consent  form  but  will  not  appear  in  the  report).  We  might   wish  to  use  some  of  your  thoughts  as  anonymous  quotes,  but  if  you  do  not  wish  these  to  be  traceable   to  you  personally  you  can  indicate  this  here.  We  will  make  notes  and  with  your  permission  we  wish  to   tape   record   the   interview   to   make   sure   we   record   your   answers   right.   After   transcribing   the   interviews,  these  tapes  will  be  destroyed.     Benefits  and  compensation:    You  will  not  gain  personal  benefit  from  participation  in  this  study.  The   intention   for   this   case   study   is   to   contribute   towards   further   strengthening   of   the   midwifery   workforce  in  your  country.       Do  you  have  any  questions?    (If  yes,  note  the  questions  and  answer)     c  Yes        c  No     If  you  agree  to  participate  we  ask  you  to  sign  below:     “I  have  been  given  an  opportunity  to  ask  any  questions  I  may  have,  and  all  such  questions  or  inquiries   have  been  answered  to  my  satisfaction.  I  hereby  consent  to  participate  in  this  study”.   I  agree  that  my  answers  can  be  used  as  anonymous  quotes:        c  Yes        c  No     Name:  -­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐     signature:-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐  Date:   -­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐  

April  2012.    

 

 

 

 

 

 

 

 

 

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Hbci og revised 19apr12 en