Human Resources for Maternal Survival

Statement of Thoraya Ahmed Obaid, Executive Director of UNFPA

Distinguished participants,

Colleagues and friends,

I thank you for inviting me to this meeting, especially since UNFPA is an organization about prevention rather than treatment. I could not agree more with previous speakers that we need a major global effort of unprecedented scale to address the crisis of human resources and the tragedy of maternal mortality. This is part of the challenge of health human resources, including Mid-Level Providers, and the response is found in the package of health services that are accessible, affordable and of quality. Our common goal is to ensure equity and the right to health.

We welcome Mrs. Gordon Brown and the Right Honourable Keen for being with us in the opening session and for reiterating the commitment of the United Kingdom to providing support to the development of the health system, with emphasis on health human resources and for maternal survival.

Today most developing countries will not meet MDG5 unless there is significant investment into strengthening their health systems, and in particular health workers.

As we talk today about investment in health human resources, we have in the background all the crises that have fallen upon our globe—energy, food, climate change and the environment, and finance, none of which were mentioned by the earlier presentations. They are interlinked one way or another because central to all of them is their impact on people. Our message should always be: we have to protect the gains that were achieved and ensure that the impact of these crises is not as deep as we fear. Whatever decisions are being made, especially within the context of the financial crisis, we need to ensure four things take place:

1) People remain our main focus since any further deterioration in their lives reinforces the loss of their human rights and their further impoverishment. Furthermore, we have seen examples of how the food crisis has led to social and political instability in some of the poorest countries, at a time when such stability is greatly needed for development interventions to succeed.

2) Donors protect the Official Development Assistance from the impact of the financial crisis so that investment, specifically in the social sector with health and education as central, will be given the necessary priority. We have raised the expectations of many developing countries and we made many promises. Meeting these expectations is a challenge to which all donors must courageously face by making money flow so that it can work for all those impacted at this crisis time.

3) Developing countries do no repeat the ‘structural adjustment’ experience of dealing with budget deficits by decreasing allocations to the social sector. This is the minimum support for people and communities for without social services, more people will fall into poverty in all its manifestations.

4) In this context, investment in the health system and especially in mid-level health providers is critical to scaling up the response to the Right to Health. They are essential components of the package of health services addressing the health needs of communities.

I believe the challenges can be surmounted but they require continuous vigilance about the rights of the communities and individuals and the urgency to listen to their articulation of their rights; it is our responsibility to support them to realize their rights.

Momentum is building to deal with the financial crisis, which is a longer-term issue. Also momentum is building in the health sector and its challenges can be surmounted if we give it the priority it deserves. There are increased partnerships, including the International Health Partnership and the innovative mechanisms for finance as well as promises of rising funding with a focus on strengthening health systems. We hope these promises will be kept.

There is widespread and growing demand for strong primary health care, and renewed commitment by WHO, as reflected in their World Health Report 2008, and other development partners to strengthen primary healthcare to become more equitable, inclusive and fair.

And there is growing awareness and political commitment to meet the two targets of MDG5—to reduce maternal mortality by three-fourths and provide universal access to reproductive health by 2015. We hope that promises of US$ 2 billion as additional resources made in the United Nations General Assembly High-level Event on the Millennium Development Goals, held in New York in September 2008, will materialize.

At the same event WHO, UNFPA, UNICEF and The World Bank issued a joint statement, pledging to intensify our joint support to countries to achieve MDG5.

Now we need to build on the foundation that has been laid and accelerate efforts at the community level where services and health workers are desperately needed.

We have to approach health system strengthening with a focus on human rights and health throughout the life cycle. Health systems are social systems and they need to be inclusive and responsive.

We need to work with communities, taking a culturally sensitive approach that engages positive elements and values of the community. This will facilitate change from within so that communities demand their rights, including the right to health, and address root causes of poor maternal health, including gender inequality, low access to education for girls, child marriage and adolescent pregnancy and all harmful practices that deny women their human rights.

In order to reduce the number of women dying from maternal causes, we must ensure that every pregnancy is wanted and every birth is safe. And while this meeting focuses on mid-level providers (who are forgotten sometimes), and who are urgently needed. I would like to stress that we also need first-level providers, such as community health extension workers, who are best equipped to provide family planning education and services. These health workers are often mentioned and discussed but they lose in the quality of their training and contribution. We cannot forget that family planning alone can reduce maternal mortality by at least a third and child mortality by at least 20 per cent. We need a team of health workers of different levels and different qualifications to address the health needs of communities and especially to address challenges of maternal survival.

To ensure progress, in addition to the mid-level health providers and community based health extension workers, we need strong supply systems that provide quality drugs, supplies and equipment. It is critical that we work together to build a supportive environment for health workers so they can enjoy improved status, better working conditions and compensation and have incentives to stay in their countries and communities.

As global development partners, we need to focus on developing and defining global actions that support regional and national strategies. We need to support implementation of the Maputo Plan of Action to expand sexual and reproductive health services throughout Africa and its integration into the maternal and newborn health roadmaps in Africa.

This year UNFPA carried out a preliminary assessment of the national maternal and newborn health roadmaps in Africa. Of the 45 countries with national roadmaps, data is already available for 30 countries. Twenty-eight have developed maternal health plans or are close to finalizing them. Fourteen countries have developed plans to scale up services to reach women in remote and rural areas. And 14 countries have begun to develop a national human resources strategy specifically for sexual and reproductive health, including maternal health services.

I bring these preliminary results to your attention because they highlight a critical gap that must be confronted. Of the 28 countries that responded, only 14, just half, have addressed the critical issue of human resources for maternal health. So clearly there is a need to support countries in developing and implementing these national strategies.

We also need to identify and support innovative human resources solutions, which are so desperately needed to solve the health worker crisis. As speakers before me have stressed, one innovative solution includes strengthening the use of so-called mid-level providers, as part of the teams needed to deliver emergency obstetric care.

Already today, mid-level providers—such as midwives, clinical officers, assistant medical officers, and surgical technicians, are providing the bulk of basic emergency obstetric care in Africa. In Tanzania, Malawi and Mozambique, they also provide over 80 per cent of comprehensive emergency obstetric care, including obstetric surgery, as we heard earlier, and this is saving women’s lives.

But we know that mid-level providers need an enabling environment to continue, expand and improve that care. At the center of this effort must be a commitment to scale up the production and deployment of competent and motivated midwives and others with midwifery skills. To increase maternal survival, we must address the gaps in midwifery.

A recent mapping exercise in 9 West and Central African countries found that in five countries, midwives are not allowed to provide the full scope of basic emergency obstetric and neonatal care that is needed. In six countries they are not able to provide the full scope of contraceptives due to lack of training. And there are severe shortages in coverage, with most midwives positioned in the capital and urban areas, leaving big gaps in life-saving care in remote and rural areas.

So to summarize, I would like to stress four points.

1. We need to focus on first-level community health providers to ensure that every community has access to family planning education and services.

2. We need to scale-up the training and deployment of mid-level providers, especially midwives, to provide skilled attendance at birth and emergency obstetric and newborn care.

3. We need to actively support countries to develop solid national strategies for human resources for health. And as development partners, we need to make sure that our own policies are not contributing to health worker migration and shortages.

4. Finally, we must continue investing in the health sector, especially in human resources, in order to scale up national responses to decrease maternal death and disability. At UNFPA, we have established a Maternal Health Trust Fund but I can tell you that funding is slow in coming.

I would like to close by repeating Margaret Chan’s words that the successful interventions to save women’s lives at the community level, through family planning to space and plan pregnancies, skilled attendants at birth, emergency obstetric care when needed, and care of mother and infant after birth, are together a proxy for a functioning health system.

This is an important message for setting priorities within the present global financial situation—investing with new money - in quality mid-level health providers is the way to go.

Thank you.