IFGH 2012: Health Systems Strengthening for Equity (HSSE)

January 30, 2012

Authors:Lobis S.1, Mbaruku G.2, Kamwendo F.3, McAuliffe E.4, Austin J.1, de Pinho H. 1

Author Affiliations:1Averting Maternal Death and Disability Program (AMDD), Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, USA  2Ifakara Health Institute, Mikocheni, Dar Es Salaam, Tanzania , 3University of Malawi, College of Medicine, Centre for Reproductive Health, Malawi, 4Centre for Global Health, University of Dublin, Trinity College

Option 1– Scientific / Empirical Research Findings Presented as – Oral Presentation


A fundamental impediment to the delivery of Emergency Obstetric Care (EmOC) is the acute shortage of health professionals in low-resource settings. Many countries have introduced a variety of innovative strategies to expand access to such personnel, including task shifting and sharing of tasks among and between different professionals, the expansion of scopes of practice of existing health providers, and the introduction of new cadres of clinicians particularly in rural areas where doctors are scarce. Policy, regulation, training, and support for cadres adopting tasks and roles outside their historical domain have lagged behind the practice shift in service-delivery on the ground. The Health Systems Strengthening for Equity (HSSE) project sought to assess the alignment between national policy regulation, pre-service training, district level expectations and clinical practice over cadres providing some or all components of EmOC in Malawi and Tanzania.


A mixed methods approach was used, including key informant interviews, a survey of District Health Management Teams, and a survey of health providers employed at a representative sample of health facilities.


This study found 3 areas requiring further consideration: 1) the lack of alignment between national policy and regulation, training and practice of EmOC, particularly among the lower-skilled cadres e.g. Nurse technicians and medical assistants performing tasks that they are not trained or regulated to perform; 2) general alignment between district level expectation and actual practice e.g. in Malawi the district health management teams generally believed that registered nurse/midwives should provide 6 of the 7 basic signal functions but only 9% of the cadre reported providing all basic EmOC signal functions; and 3) a confusing picture of actual provision of EmOC signal functions, with noted absence of assisted vaginal delivery as a signal function that is rarely taught, regulated or practices by many of the cadres, particularly in Tanzania.

Discussion/conclusions/ implications:

Better alignment between policy and practice, and support and training, and more efficient utilization of clinical staff are needed to achieve the quality health care for which the Malawian and Tanzanian health ministries and governments are accountable.



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