1. AMREF Health Africa International Conference Nairobi 25 November 2014 Dr Giorgio Cometto, Global Health Workforce Alliance World Health Organization Community health workers and midwifery workforce: reflections on evidence and future agenda

2. 2 |2 | Human resources for health: global challenges, global opportunities Source: Campbell et al, GHWA and WHO, 2013

3. 3 |3 | Community health workers: an opportunity for maternal and child health, HIV, TB … "Lay health workers provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care" Lewin et al, Cochrane Rev, 2010 "Community health workers …were found to be especially effective in promoting mother-performed strategies (skin to skin care and exclusive breastfeeding)." Gilmore and McAuliffe, BMC Public Health 2013 "Community health workers were reported to enhance the reach, uptake and quality of HIV services, as well as the dignity, quality of life and retention in care of people living with HIV. The presence of CHWs in clinics was reported to reduce waiting times, streamline patient flow and reduce the workload of health workers. Clinical outcomes appeared not to be compromised." Mwai et al J Int AIDS Soc 2013

4. 4 |4 | … and more "Non-specialist health workers have some promising benefits in improving people's outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol-use disorders, and patient- and carer-outcomes for dementia" van Ginneken et al, Cochrane Rev, 2013 "Overall, the studies consistently identified positive outcomes associated with CHW-delivered interventions, including decreased asthma symptoms, daytime activity limitations, and emergency and urgent care use." Postma et al J Asthma 2013 "CHW programmes can have large impacts on the control of Buruli ulcer in sub-Saharan Africa." Vouking et al, Pan Afr Med J 2013

5. 5 |5 | Midwifery scale-up could avert 83% of all maternal and neonatal deaths, stillbirths Source: Homer C, Friberg I et al, Lancet, 2014

6. 6 |6 | Success in reducing maternal mortality hinges on facility births and midwifery scale-up Source: Van Lerberghe W, Matthews Z et al, Lancet, 2014

7. 7 |7 | Midwifery-led services can have better outcomes than standard care models Source: Lassi Z, Cometto G et al, WHO Bulletin, 2013 Lower use of intra-partum regional anaesthesia and episiotomies in midwifery-led care compared to traditional physician-led care

8. 8 |8 | Value for money of CHWs investments "Using country GDP per capita as the WHO reference threshold for cost- effectiveness, all three CHW programmes found to be cost-effective. Incremental cost per life year gained was estimated to vary between $82 and $3,396.... the CHW-led approach has a high likelihood to be a cost-effective approach to delivery of some essential health interventions." McPake B, Edoka I et al, GHWA and WHO, 2014 (Health Systems Research Symposium abstract; forthcoming publication)

9. 9 |9 | Value for money of midwifery investment 16-fold Return on investment in terms of lives saved and costs of Caesarean sections avoided through investments in midwifery education and deployment to community- based services. (State of the World’s Midwifery, 2014)

10. 10 | The next frontier: CHWs in health systems Community preparedness Regular and sustainable remuneration package Opportunities for professional development Ensure supplies/ equipment Effective referral systems Regular monitoring & supervision Clear/ transparent selection system involving communities Curriculum to include scientific knowledge on basic preventive and curative care Adapt contents to health system need s Include CHWs in HRH planning Have a budget line / resource allocation Planning Production/ Education Deployment / retention Perfor- mance Source: Bhutta et al, GHWA, 2010

11. 11 | The next frontier (2)! Effective coverage of midwifery care workforce is AVAILABLE? workforce is ACCESSIBLE? workforce is ACCEPTABLE? workforce provides QUALITY CARE? AVAILABILITY ACCESIBILITY ACCEPTABILITY QUALITY A midwife is available in or close to the community As part of an integrated team of professionals, lay workers and community health services Woman attends A midwife is available As and where needed Financial protection ensures no barriers to access Woman attends A midwife is available As and where needed Providing respectful care Woman attends A midwife is available As and where needed Providing respectful care Competent and enabled to provide quality care. CRUDE COVERAGE EFFECTIVE COVERAGE Source: SoWMy 2014

12. 12 | Global shifts in causes of DALYs (1990-2010) Source: IHME, 2013

13. 13 | Pregnancies in 73 SoWMy countries (1950- 2100) Source: SoWMy 2014

14. 14 | Remember the future! Consider long-term vision for CHW integration CHWs often seen as short-term stop-gap measure But increasing and evolving needs on the horizon, i.e. "0" targets, growing NCD burden, demand for quality Fiscal space improvements will allow greater investment in skilled HRH Role of CHWs to evolve over next decades: less diagnostic/ curative, more health promotion, chronic care management, treatment compliance Plan for CHWs with the country's long-term needs and vision in mind Envisage evolving role for CHWs in health systems Tailor selection, education, career pathways accordingly

15. 15 | Remember the future (2)! Enable midwifery scale-up and practice Enabling policy environment Enabling practice environment -align job titles, roles and responsibilities -allow to practice within full scope of profession -strong linkages education/ employment -licensing/ re-licensing systems -improve salaries -incentive for rural deployment/ retention -access to effective referral -professional development opportunities

16. 16 | Further information Health Workforce Department, WHO & Global Health Workforce Alliance World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: ghwa@who.intghwa@who.int http://www.who.int/workforcealliance/en/ http://unfpa.org/public/home/pid/16021 http://www.thelancet.com/series/midwifery