 I welcome Petra, she's currently in Spain and she's the Director for Reproductives, maternal and newborn and child health. She's been a plenty of experience working with an independent midlife. She also manages and develops for organisations and public project partnerships. Mae'r gweithio'r gweithio'r gweithio'r gweithio, mae'n gweithio'r i'r ICM, ac mae'r cyntloedd yn cael ei gweithio'r cyffredinol i'r ICM ac mae'r gweithio'r gweithio'r gweithio. So, ydych chi'n gweithio'r gweithio? Thank you very much, Sarah. Thank you for that introduction. Let me just correct on the form of ICM Secretary General. I was with ICM from 1998 to 2003 and then went on to do the partnership for Maternal New Warrant Child Health at WHO. So, after having been away from Maternal Health for a couple of years, what we are doing now at ICS Integrary and what I'm about to present to you today is really very helpful and nice to get you back closer in connection again with both my former areas of work, both the partnership and ICM. So, first of all, happy international days and goodbye to everyone. Thank you that I've sent any of you online. I see we have 110 participants and the number is still going up, so I'm quite impressed. It's like a really full room. I'm going to talk to you about something very different from the previous session. This is really much more from a global health perspective from how can we improve access and quality of needs with free care. In countries where there are still a lot of women dying, obviously needlessly. So, what we've decided or what we've started to do together with the UN agency, WHO, UNFPA, UNICEF and others, the World Bank, but also with a lot of NGOs in countries and a lot of support from large groups like IntuPygone, Care etc. is to try to get a sense of what's going on with the military workforce or the maternal new born health workforce. So, not just midwives, all the people who work in maternal health in countries where maternal mortality and new born mortality rates are still very, very high. So, why is it that it's difficult for them to get access to midwives? What's going on in the labour market? Not just, you know, what's going on with, are there enough of the MNH workers or the midwifery workers? But what's going on? Why is it that they're not available to all the women who need them? So, I'm going to give you a little bit of the background, how this came about, why we're doing this, what a midwifery workforce assessment is, how to do it, and then looking at what is the outcome, what are the results and what do you do with them, how do you read them once they've been developed. So, the background of the internet of this work really comes from a lot better things that happen at the same time. In 2010, next to the women deliver symposium, there was a midwifery symposium in Washington DC the first ever. And there was a big focus on midwifery, midwives, and out of that came several initiatives. One was to, you know, help countries look and further develop their workforce. Others were to strengthen country initiatives and work that countries have done and also to create better intelligence, more literature around midwifery. The workhouses of this, the proposals that came forward went to a meeting called the Green Tree Meeting, which took place in September of 2011, and where quite a few Ministers of Health in response to the State of the World midwifery report, which was launched at ICM in 2011, also said that it's important for them to have an opportunity to look at their workforce assessment and their workforce in particular. So, in the left side of this slide you see the eight countries who, at the Green Tree Meeting, decided that they wanted to have a midwifery workforce assessment done. You'll see in the slide underneath what the maternal mortality numbers are in those countries in the middle bit, and you'll note that this together, these countries together, contributed 60% of the global maternal mortality. In addition to that, several other countries working with Muscoca funds, which is a Canadian and French francophone initiative to reduce maternal mortality, decided that they would also like these midwifery workforce assessments undertaken. So, a couple of others are using the same methodology with support from integrated with Secretariat for this work, but also working with other partners to get a better sense of what happens with the workforce, midwifery workforce in their country. So, what you see in this slide is that there's a great interest for doing work, there's a great interest for finding out what's going on and why there are so many complications. And every country that we're doing, at the moment we've done, Afghanistan, Bangladesh, Ethiopia and Tanzania, the Muscova countries are starting up, which DR Congo is the furthest and next on our list are Mozambique, Nigeria, South Africa, and hopefully also Mexico. What you're seeing is that the situation is very different in every country. So, the way we're doing the work, the analysis, is really to give the opportunity for countries to understand what specifically for them are the issues they need to address. So, if we look at the global agenda, another is, of course, it's also feeding into a lot of the work that has to happen in the post-MDG, the Millennium Development Goals will come to an end officially at the end of 2015. So, there's already a big discussion going on around what are the next steps, what are we going to do after the end of the MDGs in 2015. And the issue there is that there are a lot of issues scrambling for attention, health is not only and definitely not the primary goal anymore. Sustainable Development, economic strength, reducing poverty, those are all things that are very visible and very high on the agenda climate change, of course, as well. So, health is going to be in a subset, in the much larger subset of topics than it was in the MDGs where it was very common. So, as you see this calendar, there are quite a few opportunities in which we're going to be able to put together and strengthen the understanding for many people, not just in these countries where we're doing assessments. Of the importance of the military workforce, there are a lot of goals and ideas that you can want to make happen, but unless you have the people who are going to do this and the policies are going to be implemented and are carried out by health workforce, nothing is potentially going to change. So, the overall arching question that we looked at is what is the appropriate military workforce and other countries will call it maternal health or maternal newborn health workforce, or I predict a maternal newborn health workforce. How is it best deployed, so how does it best get to the areas where it needs to be? To equitably deliver essential M&H interventions at scale and at quality. Equitably deliver, with that, we mean that everybody has access to them, no matter if they're rich or poor, no matter if they're far away or close to a health facility. The essential M&H interventions are those that have been agreed as the life-saving ones and those that are essential to prevent and treat complications as they start. At scale means that they are available to everyone, so to 100% coverage to the best possible coverage in a country and at quality, which means that they need to be provided by people who are fully competent in military or maternal newborn health. What including cost needs to be put in place to achieve this universal access, so you'll see the emphasis is on equity, everybody needs to have access, quality and effective coverage. So this is a very complicated slide and I'm going to just explain it really briefly to you, but in case you want to look back at it in more detail. So what we do first is a desk review, which is what we call the preparation. We look at what's happening in the country, what's the need in the country and what is the availability of staff in a country. And we look in that regard at things like policies. What are the policies that determine or that define where military services are provided, where the health system can do, how supported it can be to maternal health, how does it finance, what is the need to the population, how many pregnancies can we expect and we project that and you'll see that in one of the slides up to 2025. And what are then the care needs, what are the people who are working in midwifery or in maternal health doing you, is doing what, what does the nurse midwine do, what do the subsidiary do, are there roles for community health workers, what's by the secondary and tertiary levels of care. And then we look at the, at the triple HU, availability, accessibility, acceptability and the quality of care. So after we've done this analysis and we've looked at all these core data, we identify if there are any gaps, you know, what are we missing. For example, in Tanzania we were missing what people are actually doing at a facility level. How do we see, how do we know what a midwife is doing, what a nurse is doing, what a doctor is doing, do they refer, do they, what do they take care of themselves. And so, for example, we've got to those parts of Henry's or constructed labour, what are the issues that the computations that they send on, do they categorically send everything on, which was the case in some facilities. So how, how, how does it work and how much time do M&H workforce as they're called in Tanzania spend in actual prevention and treatment and the basic assessment that they needed for maternal and new born health. Because you can see that sometimes if people have more than one skill or have a, you know, their nurse midwife and they can do other things that could also be pulled into A&E or they could be pulled into HIV programs and in essence that means that their capacity for 100% time spent on maternal and new born health is reduced. So we do, we find together with local research institutions and also with local midwives and nursing and OBGYN associations, we try to find the data that is needed to give us a better detailed picture and not only looking at what happens in the, generally in the country but also at the disaggregated level so that we can see exactly what's going on in the more remote and rural area. So with all those data together we then do an analysis of what is, where is midwifery, who is accessing it and what is the effective coverage, does the country want to go to 100% coverage, is it looking at 50% or 60% as its set goal for itself to reach 100% by 2010, 2015, 2020. And then we kind of make a set of what we call costed policy options so we say if you increase training then that's all cost so much and it will reach so much but if you then don't also move deployment or providing centres for attention in those remote and rural areas etc. So we, we develop what we are calling costed scenarios so that the government has a real notion, a real understanding of if we take this option this is what it's going to cost and this is what it's going to bring up because ultimately, a minister of health who wants to improve maternal new born health is going to have to negotiate for funds with a minister of finance and he'll need a lot of political policy with respect to financial arguments to make his case. So this is one of the first steps and it's a really interesting way of looking at what's going to happen in a country. We kind of pull together the pregnancies and the redder, the more pregnancies that there are to be expected. So we look at where people live and we calculate how many pregnancies are based on a social facility rate taking out certain percentages for spontaneous abortions, carriages and things like that. And we have a sense we can give a picture for say this is a standalone picture for three countries. We also give for example three pictures for Afghanistan in which you can see by the change in the colour where people are, where more pregnancies are to be expected, which helps a government tailor some of its planning to the areas where the needs will be greater in 2010 or 2020 or 2025. And then we look at what is the, you know, what are the people who are doing these services, who are providing what and we do that per essential intervention. So WHO and the partnerships between the new born and child health have made a list of the essential interventions between the new born health and they start, you know, all the way in basic screening, et cetera, et cetera, but also things like dead nets and tetanus and you know, HRV and all those kind of things. So all these essential interventions are assessed per provider. So what do CHWs do and what do nurses do and what the community which wants to do, what the OBGYNs do. So the we can get a kind of a sense of, so the main providers in the M&H workforce in this country are X, Y and Z and we usually come up with a group of three or four Cardo's or community health providers. We can then target much more of our data collection and the details that we need on what they're providing. So if we then look at what the whole labor market looks like and how that works, I mean, this is not a health system or a health related issue only it's really, you know, the whole, any kind of a labor market looks, looks like, you know, looks at what are, what is our pipeline, how are we going to be, how are we going to look at the people that are going to come into a certain area of work or in a certain profession in the future. So you start from high school graduates and you look at how many of those stream into healthcare education and training as of those, how many are then qualified, which gives you a sense of what your potential supply is. From those you have several that are employed, which is a lot of the employment run through the central government, so there are certain numbers of positions available. Obviously based on funding but also based on some of the economic situations and criteria that are determined and agreed with World Bank as conditions for loans and the INS. So there are a lot of influences on how many people can be employed. Some of them will be unemployed, some of them will have executed to other jobs. So how many are unemployed is actually then going to the health sector because there could be some going to something else like academia and pharmaceuticals etc. And then out of those how many come into the public and into the private sector. So you'll see if you look at the big bar of high school graduates at the bottom, how many you could potentially be left with in the public sector. Who would then be available to be sent or to go to take care of people that need this research. So if we're looking then at how many, what the cost is, is one of the things that we try to address. So what does it cost to train a midwife? What does it cost to train a nurse? What does it cost to train an auxiliary? What does it cost to train a community health worker? And then compare that to what they do in the slide that we showed you earlier. I showed you earlier, you can get a census to what is the best economic benefit. What is the group of providers that we can educate for a relatively affordable cost and who can kind of cover as many as possible of the essential intervention. So that you have a lot of skills in hand with one person. And then you have the issues of what the triple A keywords we call it work like. So if you look at what's available, on the left there's a situation in the rural areas of the country and on the right it's in the urban areas. So availability in the rural area is quite a lot lower than availability in the higher areas. So the means that the purple blob is on the left, more to the left of the middle of the chart from the left hand sign in the rural side than on the right hand sign in the urban. So there are more people available in the urban areas. There are also more easily accessible in the urban areas. So you see that even though they are available accessibility has an impact from that. There are many areas in the world where despite living in a city people are still very poor and being able to access services has a financial cost. If you look at accessibility in a rural area of course their transportation and distance taken impact. So you see that's why the purple blob has gone even further to the left. Moving up to acceptability which is really our providers giving the kinds of services that women find acceptable. Are they culturally correct? Do they kind of respond to the needs of women? Are they acceptable in the community and in the culture in the family of the women? Both of those in rural and in urban situations make the availability, the social availability and the coverage of built birth attendance on the twice much lower. And then of course the number of times that you actually contact is that there are, how many people really actually go to these services despite that they would be available accessible and acceptable reduces the number. So is it the top you find worth effectively? Does you calculate around 45% if you look at the number left in rural or 45%? That would be available effectively about 10% are going to be used and in the urban areas there would be 80% available effectively. There would be about 30 to 40% maybe probably just about 30% that's actually effectively going to be used. So if a country has a coverage target as they're saying they want the country to be covered for 60% by accessible available acceptable built birth attendance or M&A services then just because of this impact of one of the on top of the other they'd have to put a lot more energy into making them available accessible and acceptable to get to their 60% target. So those are interesting pieces of information for a government to understand and tweak their policies on. So if you then look at what you have, what the story is, on the left of this you see the stock. So this is the number of work that the workforce there currently is. And on the right hand side, in the year X, as I'm saying, when we model for 2020 or 2025, you see exactly how much you need. And of course you can use the need and put in a service target. So if we're here projected for 100%, but you could imagine that the country that's only protected, that's only wanting to cover 60% would have a lower bar on the right hand side. So between the stock, the number of people that there are and what you need, usually people make a kind of a linear decision. So okay, we need to train more mid-wise, we need to train more doctors, we need to have community health workers who can do more X, Y and Z, et cetera. And if you look at the small graph in the middle, actually the story is a little bit more complicated because of this entering into the education stream. Those that come out of the education stream, you'd think there were as many as went in, but there are quite a few that you lose along the way because they go to another area of work or because they find that they don't get employed or because they don't get to the place where they're supposed to be working. So in essence, though, you think if you add the stock plus the entry, you would have about 60% or 70% of your needs covered. In essence, you only have 50% or 45% covered and the gap is much larger. So all these are ways of making it insightful for government to find their way through this maze of impact and influences on the middle of free and internal health workforce. So in the reports that we're doing, this is an example from Ethiopia, we provide what we call an infographic, which is a piece that really in a very short, in a quick overview gives an impact, an image of what the situation is in the country. So, of course, you have what the situation is, the needs, the supply, what the gap is, and then what the strategies are for getting the middle of free and the family of health services out there. So this is something that is for policy makers and for development partners, international organisations, but also midwives and middle free associations of UINs, becomes a very easy to understand and easy to use tool that will help them in their discussions and their negotiations with the government as to how to improve services. Because, of course, in addition to this, this is the workforce component, there are also a lot of other tools that have already been developed that are being used in these negotiations that talk about the health system, the quality of the facilities, the reachability and the accessibility of the services at the facility, you know, have they got full equipment, can they do all the life-stays and interventions. So then you have the two biggest impacts on M&A services in the country, what are the facilities like, how can people get their support, but also what is the workforce that supports. So this is the last slide with some information on the main people who are working on this. I'm sharing myself with our staff that are based in Tigraria, I work at the Zardiniza area and Jim works from Barcelona and our main connection for this work, our main person that we work with is Feliz de Brenis at UNSPA in Ziniza as well. He works on the topic on behalf of what they call the H4 Plus, which are the UN organisation, sorry that's a concern, but it's the UNSPA in the World Bank, UNA to UN Women. So I think I'll leave it there. Any questions for clarification please do feel free to let me know and then of course we can start a longer discussion on some of the areas that you might want to give me your opinion or suggestions on. Thank you. Thank you. Does anybody have any questions? There are some people writing in the chat box. It was a great presentation to her. Amazing work. It's really interesting. It's very rewarding as well. Well, yes, because it's about the midwifery workforce, but also because it's really just, you know, it's life-saving and I think that's very, very important. Nicol. I'll just go ahead. Nicol, I'll answer that in writing. Some of the training innovations are to use more of the current technologies for learning, but specifically trying to find people to enter into midwifery schools. That will go back to the communities that they come from. What you see is when people in many countries that we work in find, get an education and get a profession, they all tend to want to go to the larger agglomeration by the capital city or some of the larger cities. Whereas in essence, they are so much needed in the remote and rural areas. So some of the ideas around that have been to put midwifery in nursing schools in the remote and rural areas so that they are very close to where they are, others are for communities to put forward their people to go to these schools so that they will then also go back to their communities when they finish their education. So there's quite a lot of ways in which there are, you know, people are looking at making it more attractive to increase coverage by staying close to where you're from. And it also makes services more acceptable because you know your culture intimately and would, you know, be better, be very well-placed in making services available that people really, you know, accept and that use the same language, etc. So these are only a few, there's quite a lot of other ways of being innovative around training. I'm just going to move on to the next area that there are online innovations indeed. I think that's indeed really important that the issue there is that connectivity isn't ubiquitous in the rest of these countries. So still, you know, when you use these online mechanisms, you have to be aware that they have to be available to very low bandwidth and they have to be accessed by that. There are many more technologies now with mobile phones, which I think we also should look at in a way that as a future option for doing educational work. Learning about maternal newborn health and becoming a midwife or a nurse midwife or whatever the kind of title might be really does need 50% handgun work. And I think that is not stable. You can't learn that, oh my, you have to learn that in a clinical setting. So, obviously, it would only be half useful, I think. Moving on to Caroline's question. Yes, there is definitely interest in expanding this work. We've had interest from Mexico and South Africa as countries that aren't in the original group of eight. You've seen the Muskoka, the Francophone African countries, adding to the group. And in essence, what we'd like to be able to do is to create a body of knowledge and a body of consultants and support through the Secretariat and together with the H4 that they can really carry these out. So, we're going to write, we're working along an operational guidance and framework that we would like to make available. We're looking to publish that in September so that more people can put the user system and hopefully then produce quality. I think that's important. Similarly to the emergency of such a care ways of analysing what the facilities can do in emergency of such a cases. I'll come here to say why there's a conflict in that. It depends a little bit on the countries that you're in. The ones that we've been working in, a lot of, as I was saying, a lot of the deployment and recruitment and deployment and also the tension mid-wise and the work force goes through the government. That means there is a large bureaucracy and administrative mechanism on top of which sometimes there are what we call feelings imposed by development partners, either the World Bank or INF or others, who are saying you can only use an extra percentage of your budget and of your health budget to start the rest. You have to use the X, Y, Z other topics. And that means that it's hard for the people to, for government to actually deploy and send and retain in remote and rural areas, the staff that they would like. In the situation in Tanzania, which is one of the countries we analyse, we found that about 50% of the high school of the midwifery education or the health education graduates were lost in the deployment chain. So 50% of them didn't, quote unquote, survive or didn't last between coming out of their education programme and staying in post for one year. So those are areas where there's definitely a lot that can be improved. There are other ways that governments are trying to approach this by having recruitment happen locally, which is also sometimes easier or sometimes not. It's still a bit of a struggle. And as you will probably know, health workforce is not really at the top of everybody's agenda. It's saving lives and those are the big topic. It's now the noncommunicable diseases. So when you're working on health workforce issues, it's a constant debate to convince people that without the workforce all their beautiful targets and programmes won't be achieved. Yes, in some areas midwifery are costly indeed. However, there are also many places where midwifery is provided by other kinds of cardoes, involved nurses, others who take a role or take a key role in providing and aid services. And that can be very challenging because on the one hand you want quality of care, on the other hand you're looking at the reality on the ground. So it's a question of really being strategic and creative in getting midwifery out there. In essence, I think the workforce is costly. In many countries, workforce takes up about 60% to 70% of the health budget in other countries even more. So I don't think we're going to ever be able to say that this is a quick fix or no-hanging fix. It's a sustained effort that will be sought in the long term, but that's important for people to want to and have to be enthusiastic. We have cost estimates for deployments, as I was saying in the answer to Michaela's question. We have done those in the areas where deployment is the main issue. In Bangladesh, deployment is obviously a relative role as an issue in Ireland. It's a lot stronger already. And the new midwifery has been trained there. But deployment really means adding on cost for incentives. But in many cases, for example, also schooling for children, housing, things that will make people stay in the emotional areas and actually kind of build their life there without saying, oh, I'm going to do this for three or five years and then I'm free to go wherever I want, which means capital city or outside the country, effectively. Some of the cost estimates around that are also to do, or would also include supportive supervision and ways in which people can make better use of the services that are around them. Mary, you're asking what sort of provision did you encounter in relation to maternity care assistance and report workers? Are you asking whether or not we found them and what they do? Or are you asking what kind of support these people are receiving? Which provision are you looking for? Yes. Well, there's always the presence for the low hanging fruit and the quick fix. And that's not only or not mainly government actually. And often it's the development partner to ask for a quick result and give countries an amount of years to make an improvement and then expect them to be able to sustain that improvement from their own funds, which doesn't always work. So, yeah, there are obviously, what you see is a lot of results of these quick fixes. So large numbers of community health workers, for example, in Tanzania, as I was talking about earlier, who had a certain set of tasks, but for example, haven't been taught what the signs of onset of labour are. And that would be something that would be very useful for people to be able to send women on or to keep tabs on or to inform other kinds of health care providers or the midwives around them to say she's starting a labour, et cetera. So there's a lot of little pools of programme and impact that you can see that haven't been joined up. It's a bit of a join the dots sometimes. And then there's, of course, there's the issues around what the government really wants, which isn't always all these projects. There are also governments that are proactively rejecting small projects for trained community health workers like this or make partnerships available or do this or that. They want a full, long-term sustained programme. And I think one of the results of the work on the focus on the Millennium Development Goals is that we're starting to see that long-term thinking is needed and that the invent or the investment in quality. For example, had we in 1987, when the State Model Initiative was taken, started out with midwifery programmes that would give a fully competent midwife to international or whatever the name is. Midwife, I'm not talking about specific kind of, but if it is trained to the kind of continuum of care covering quality professionals, then we would have already had a much stronger impact on the term than you would have. I see you agree, Nicole. Fundswell, are there any more questions? No? Awesome. Well, thanks so much for your presentation, Petra. I really, really enjoyed it, and I think it generated some really, really interesting expressions. It's quite inspirational what you do, and thanks so much for giving up all your time for us, and I would really hope for an update next year. Just to say that you have our contact details here. If you're working in a country or you know a country, I'm just getting a question about the OECD countries. If you wish, think that there would be interest, then please don't hesitate to write. Of course, it has to be a government initiative. They ultimately have to be the ones coming to the H14 plus to say we would like a workforce assessment, but that can always be achieved through very many routes and ways, so feel free to start a ball rolling if you know it's going to be of interest or of effect in the country that you're working in. Brilliant. Thank you very much. Thank you.