WHO recommendations: optimizing health worker roles for maternal and newborn health

In the area of maternal and newborn health, a number of practices have been proven effective
in clinical research.
However, the shortage of health workers in high burden countries means that we are often
unable to deliver these critical interventions to mothers and newborns.
One of the solutions that has been proposed is task shifting, or task sharing.
This usually involves shifting or sharing of tasks from one group of health workers
to another group who have less training, but that can be trained to provide the required
tasks or sharing tasks among different groups of health workers. And because these health
workers with less training live closer to the communities or may be available in larger numbers
delivery of these life-saving interventions may be improved.
Many countries have asked WHO for advice in the field of task shifting, so they may optimize
health worker roles and improve access to key interventions for improving the health
of mothers and children. Therefore, we have recently developed a set of recommendations
focusing on shifting tasks to different groups of health workers in the community or primary care.
These guidelines cover lay health workers, auxiliary nurses, auxiliary nurse midwives,
nurses, midwives, associate clinicians and non-specialist doctors.
This film gives further insight into the problems - and possibilities - surrounding
optimizing access through task shifting and sharing.
Some people really don't have money to pay for the transport. The distances to the clinics
are the challenges. Also, the commitment to serve from the health facilities -
commitment to serve people in the right way.
Many mothers and children rarely receive health treatment. This is often because of a severe
lack of health workers or because existing health services are too far away from where people live.
One way of dealing with this problem is to shift tasks to health workers who have less
training or to share tasks better among health workers.
Lay or community health workers could, for example, take on tasks normally done by nurses,
such as health promotion or the prevention or treatment of some childhood illnesses.
Nurses and other midlevel providers could, in turn, engage in tasks normally carried out by doctors.
Task shifting has a number of advantages. One of them is that people often appreciate
the opportunity of receiving health care closer to the place they live,
and from health workers that they know, who they think of as being similar to them in some way.
She's someone you can talk with. And then she will advise you right, your problems, you see.
And then she will show you the way, "you must go this way, you mustn't do this".
This is the way that I was, and now look at me! I'm here. She's so motivating!
I don't want to go to the hospital because the services that we get in the community
and the behaviour that we get from the community health facility is very nice.
I'm telling from my personal experience. When I go to the hospital, when I was in labour pain,
Then the hospital staff scolded me! They used bad words. Their behaviour was not good.
So I do not want to go to the hospital.
Our "mentor mothers" (lay health workers) come with an approach to respect mothers and
not to judge them. So it's easy for mothers to disclose whatever information they have
to our "mentor mothers".
The health workers themselves are often pleased to be given the
chance to expand their roles, particularly if they receive proper training and support.
It's a good thing for us. Because we are happy with what we are doing,
that we are helping people. It's a good thing. Because we don't feel good that we will just weigh
a child and leave a mother in the bed who is sick or anybody else who is ill,
and just look after children only.
In addition, many of the health workers who have delivered these tasks in the past appreciate
the help they now receive from other groups of health workers.
There won't be long queues in the clinics, there won't be a stigma to the community.
I think that can work well.
But some people are concerned that the transfer of tasks to health workers who have less training
might lead to harm.
We have to consider if the health workers who are taking up the new roles are actually
capable of doing that or not. We have to consider their capacity to carry out those functions
in quality manner. And there should be a proper mechanism to monitor if the health workers
are doing that properly or not, if they are facing any problems or not and there should
be a mechanism to support them in case of any problems they face during implementation
of those, or delivery of those interventions.
Well, the first thing that came from a doctor is "Well, we have trained for such a long time
and we are not able to do it efficiently. How will they do? And they were always talking
of the possibility of compromising the quality of the service. So that is an issue.
I will give you another example. We have started training nurses in making ultrasonic examination
of a pregnant lady. And they say that she might come up with some wrong interpretation
of the ultrasonic findings. Yes, but what is the proportion of diagnosing correctly
and what is the proportion of misdiagnosing? We found that they diagnosed correctly on
more than 95% of instances. And so 95% of people benefit.
In addition, practical problems, such as poor access to training, supervision or supplies,
may make task-shifting to new groups of health workers unfeasible.
Since it's a birthing centre, equipment and supplies need to be in place.
That makes me more efficient in my work. And more training on new health topics.
Health workers who take on new tasks are sometimes also dissatisfied with their new working conditions.
Anything new meets up with resistance. And often professionals don't want to give responsibilities
away to somebody who has less training than them. I'm not sure what the reason for that is,
whether they feel that somehow it diminishes the importance of what they do if someone
with less training is able to do a similar thing. I think that may be part of it.
And the other concern, of course, is about quality. I don't think that one can view these things lightly.
One shouldn't just expect that a lay person can do, whether it's education
or case finding or adherence support. I think it's really critical that there's a rigorous
training programme, a standardised training programme, and that the training programme
is not just once-off, but that there are refreshers and that there is some kind of mechanism for
quality assurance to ensure that they are able to perform the functions to the best standard.
Another concern is that recipients may prefer more highly trained health workers or may
worry about confidentiality.
We also have to consider the social acceptability issues. Because some of the services,
the community may not be willing to get from community volunteers or somebody whom they know.
For example, the cases of HIV/AIDS or tuberculosis, which might have some stigma associated,
they may want to go with the health workers who are not known to them. So we really have to
consider these factors and we need to customize all of these as per our country need and country
situation and country circumstances.
The solutions proposed by these guidelines can be perceived by the public as a cheap solution
And that can create some sort of rejection from the consumers, the patients
and the general public. So these are all evidence-based recommendations and they are the optimum solution
for the delivery of these interventions. And this has to be clear for the society.
These recommendations - they are combatting, they are fighting against health inequities and
they are promoting the universal access to health care.
To develop the guidance, an international panel of stakeholders systematically reviewed the evidence
weighed the pros and cons of the different options, and arrived at a set of recommendations.
The guidelines were developed through a systematic process. The WHO convened a group of stakeholders
from all over the world, with good representation from the South. We looked at the available
evidence that had been assembled by the technical team, we weighed the benefits of the interventions
versus the harms of the intervention, and made recommendations based on these.
When the guideline panel was unsure as to the safety of a particular intervention,
we recommended that the intervention be carried out in the context of rigorous research,
or could be implemented together with monitoring and evaluation.
The guideline panel did not always recommend task shifting interventions. For example
associate clinicians were recommended against doing external cephalic versions or caesarean sections.
The recommendations are options rather than prescriptions or rules. Policy makers and
programme managers need to consider these recommendations in relation to information
from their local setting regarding priority problems, the availability of different types
of health workers, costs, and so on before making a decision on whether to implement.
The guideline is a framework. So it's not specific, it's just a framework that is given by WHO.
It's up to the countries who are implementing it to tailor it as per their
need, as per their health system, as per the resources they have, as per their local settings.
Well, one of the interventions we looked at was whether lay health workers could deliver
misoprostol to protect against postpartum haemorrhage. This might be useful in a context,
for example Ethiopia, where there is a widespread network of lay health workers or health extension
workers with good referral networks. In a situation where a country doesn't have
a good, well-developed system of lay health workers, where there is poor support,
poor logistics, this may not necessarily be a good idea.
To help policy makers adapt these recommendations to their own settings, the guidance document
has highlighted several factors that can influence the success of task-shifting programmes.
To be a success, there are certain things that need to be in place.
The health worker needs to be properly trained and well supported and supervised in the system.
The referral system needs to be in place. If a health worker refers any clients to upper
health system or health services then that referral system needs to be in place.
So these are the things that I think have to be in place to be a success.
This guidance may encourage governments and organisations to formalise task-shifting initiatives
that might otherwise be undertaken in an informal way. Making processes like this more formal
is a way to give health workers better protection and support.
We have been doing lots of things that are already there in our country and are recommended
in the guidelines. So it will help formalise things. And it will open doors for other opportunities also.

In a country like Nepal, which is geographically challenged, we really need to bring the services
closer to the community. And sometimes when we need to develop that kind of policies,
we need to have a proper evidence base. We need to have supporting documents and guidelines.
And this WHO guideline is very helpful to move forward in that direction.
Our overall objective is to ensure that every mother and child who needs attention and care
receives the best option. And we hope that the policies recommended in the WHO guideline
will help the countries achieve this.