Delivering services and inﬂuencing policy: Health care professionals join forces to
Author(s)/Editor(s): The Health Care Professional Association Writing Group *1
Publisher/Organizer: International Journal of Gynecology and Obstetrics
Publication date: 2009.01.30
* André B. Lalonde. The Society of Obstetricians and Gynaecologists of Canada (SOGC) 780 promenade Echo Drive Ottawa, Canada ON K1S 5R7. Tel.: +1 800 561 2416, +1 613 730 4192; fax: +1 613 730 4314. E-mail address: firstname.lastname@example.org.
1 Members listed in alphabetical order: Zulﬁqar Bhutta, International Pediatric Association; Agneta Bridges, International Confederation of Midwives; Flavia Bustreo Partnership for Maternal, Newborn and Child Health; Andre Lalonde, International Federation of Gynecology and Obstetrics; Bridget Lynch, International Confederation of Midwives; Pius Okong, International Federation of Gynecology and Obstetrics; Jennifer Harris Requejo, Partnership for Maternal, Newborn and Child Health; Jane Schaller International Pediatric Association; Kadi Toure, Partnership for Maternal, Newborn and Child Health.
This article reviews the major activities of health care professional organizations (HCPAs), and emphasizes the role they can play in advocating forwomen and children and inﬂuencing maternal, newborn, and child health (MNCH) programs and policies. The ICM/FIGO joint effort to prevent postpartum hemorrhage and the 40-year partnership between the American Academy of Pediatrics (AAP) and the Indian Health Service (IHS) are highlighted as examples of how and why HCPAs should assume a leadership role in advocacy work. The action-oriented multicountry HCPA workshops organized by the Partnership for Maternal, Newborn, and Child Health (PMNCH) and the International HCPAs are also described. These capacity building workshops are aimed at strengthening the ability of HCPAs to organize, coordinate activities, and becomemore involved inprogramand policy development.
Approximately 530000 women and 4 million newborn babies die every year because of complications related to pregnancy and childbirth [1,2]. An additional 6 million children die each year before reaching their ﬁfth birthday . Almost all of these deaths occur in low-resource countries, and are potentially preventable through the wide-scale implementation of proven interventions [4–7]. Major progress has been made in recent years in advocacy for maternal, newborn, and child survival, and in the recognition that interventions aimed at improving maternal, newborn, and child health (MNCH) in low-resource country settings should be implemented according to the “continuum of care” approach . However,much more must be done to save the lives of women, newborns, and children if the world is to achieve the Millennium Development Goals (MDGs) 4 and 5,which call for the two-thirds and three-quarters reduction in child and maternal mortality by 2015, respectively.
Global progress toward MDGs 4 and 5 hinges upon a shared commitment to MNCH and close coordination among governments, civil society, and assistance agencies. As members of civil society, health care professional associations (HCPAs) are key partners in this collaborative effort. These associations are composed of highly trained professionals including physicians, nurses,midwives, and pharmacists who are directly involved in promoting and implementing essential interventions, and are responsible for the delivery of care to mothers, newborns, and children. Given this, HCPAs have the potential to impact MNCH in several crucial ways. HCPAs can serve as advocates for women and children through lobbying activities, participating in the design and implementation of national-level MNCH plans and policies, and by mobilizing communities to demand greater political commitment to MNCH. HCPAs can also play a critical role in ensuring the quality of services through monitoring and evaluation efforts, establishing standards of care, increasing the scope of training and educational opportunities for health care providers, addressing the human resource crisis, and by promoting better team work within the health care system [9,10].
The important role of HCPAs in developing standards of care and updating and improving training and educational opportunities for health care providers is well established. The ofﬁcial websites of the international HCPAs, including the International Federation of Gynecology and Obstetrics (FIGO, www.ﬁgo.org), the International Confederation of Midwives (ICM, www.internationalmidwives.org/), the International Pediatric Association (IPA, www.ipa-world.org), and the International Council of Nurses (ICN, www.icn.ch/program.htm), for example, all provide a wealth of information on available educational programs and instructional tools, awards and fellowships, and activities facilitating knowledge transfer and the fostering of relationships between high-resource and low-resource country HCPAs. The international HCPAs, individually and through productive partnerships with each other and other organizations, have assumed a strong leadership role in advocating for MNCH in recent years. Representative examples include the 2003 and 2006 ICM/FIGO joint statements on the prevention of postpartum hemorrhage (PPH), FIGO's partnership with UNFPA and other committed parties resulting in the launch of the Global Campaign to End Fistula in 2003, and the IPA's “New York Call to Action from Pediatricians of the World” drafted in 2002 in conjunction with WHO and UNICEF and followed-up with the 2006 “Millennium Call to Action for Pediatricians of the World.” Through establishing alliances withUNagencies and other organizations such as the Global Alliance for Vaccines and Immunization (GAVI), International Planned Parenthood, and the Partnership forMaternal, Newborn, and Child Health (PMNCH), HCPAs are also increasingly positioning themselves as instrumental to the design and implementation of MNCH policies and programs.
The remainder of this article is organized into two sections. The ﬁrst explores in greater depth the ICM/FIGO collaborative effort to prevent PPH, and the 40-year partnership between the American Academy of Pediatrics (AAP) and the Indian Health Service (IHS) as illustrative examples of how and why HCPAs should effectively advocate for the improvement of the lives of women, newborns, and children around the world. The second describes in detail a series of multicountry workshops organized jointly by the PMNCH and the international HCPAs, with the principle aim of enhancing the ability of HCPAs at the national, regional, and international levels to inﬂuence MNCH policy and program development and implementation.
2. HCPAs acting as advocates for MNCH: A spotlight on two key examples
2.1. The ICM/FIGO joint effort for the prevention of postpartum hemorrhage
At the 2003 FIGO World Congress in Chile, President Arnaldo Acosta announced that FIGO, in partnership with ICM, would launch a global initiative to prevent PPH—the leading cause of maternal mortality—and increase the knowledge of health care providers about management and surgical treatment options . This announcement was followed by the release in November 2003 of the ﬁrst ICM/FIGO Joint Statement entitled, “Management of the Third Stage of Labour to Prevent Postpartum Haemorrhage” . In this joint statement, ICM and FIGO pledged to take on a leadership role in advocating for universal access to skilled delivery care and promoting the active management of the third stage of labor (AMTSL) as essential interventions for reducing the incidence ofmortality related to PPH. This statement also describes a set of recommended practices for the prevention and treatment of PPH, and calls for additional research to test the efﬁcacy of potential interventions. Working in collaboration with the Program for Appropriate Technology for Health, EngenderHealth, and RTI International, ICM and FIGO introduced the “Prevention of Postpartum Hemorrhage Initiative” in 2004 (information on the initiative is available at: www.pphprevention.org) and committed themselves to spearheading 10 key actions:
- disseminate the joint statement to all national associations of midwives and societies of obstetrician-gynecologists, and encourage the national groups to disseminate it to their members;
- obtain support for the joint statement from agencies in the ﬁeld of maternal and neonatal health care, such as UN agencies, development, and others;
- recommend that this Global Initiative on the prevention of PPH be integrated into the curricula of midwifery, medical, and nursing schools;
- recommend that the Global Initiative be adopted by health policy makers and politicians;
- every mother giving birth anywhere in the world will be offered active management of the third stage of labor for the prevention of PPH;
- every skilled attendant will have training in activemanagement of the third stage of labor and in techniques for the treatment of PPH.
- every health facility where births take place will have adequate supplies of utero tonic drugs, equipment and protocols for both the prevention and treatment of PPH;
- blood transfusion facilities are available in centers that provide comprehensive health care (secondary and tertiary levels of care);
- physicians are trained in simple conservative techniques such as compression sutures and devascularization;
- promising new drugs and technologies for the prevention and treatment of PPH, such as the tamponade technique, are evaluated;
To incorporate scientiﬁc evidence that became available after the release of the 2003 statement, a second ICM/FIGO joint statement, “Prevention and Treatment of Post-Partum Haemorrhage: New advances for Low Resource Settings,” was launched at the 2006 FIGO World Congress in Malaysia . This statement reiterates FIGO's and ICM's commitment to work together at the international and national levels toward the goal of making skilled delivery care and ATMSL available to all pregnant women. The ICM/FIGO joint effort to address the persisting problemof PPH is an important example of the power of partnership, and serves as a model for future collaborations between HCPAs. Through working together, ICM and FIGO were able to create high-level advocacy tools promoting the broad-scale adoption of speciﬁc strategies for the re- duction and treatment of a major cause of maternal mortality, and engage other agencies in the launching of a global initiative.
2.2. The 40-year partnership between the AAP and IHS
The 40-year partnership between the AAP and IHS and its impact on the health of American Indian and Alaskan Native (AI/AN) children is well documented in Brenneman et al. . This ongoing partnership serves as an exemplary model for how a national-level HCPA can successfully collaborate with a federal agency to signiﬁcantly improve newborn and child health in a disadvantaged population group. The authors detail the consultative and advisory role the AAP has played in the health and health care of AI/AN children since 1965, and describes the Congressional and Senate subcommittee meetings where members of the AAP lobbied on behalf of AI/AN children to push for the passing of the Indian Health Care Improvement Act of 1976. Although careful not to attribute causality, the article notes that the efforts of the AAP likely contributed to the remarkable and steady declines in the neonatal, postneonatal, and child mortality rates in the AI/AN population observed in the post-1965 period.
3. The multicountry HCPA workshops: A capacity building initiative to maximize the ability of HCPAs to collectively organize and contribute to MNCH planning and policy development
3.1. Rationale for the development of the HCPA workshops
The ability of HCPAs to contribute to the advancement of MNCH worldwide has been hampered by the lack of organization and communication across and within HCPAs, particularly in low-resource countries and at regional levels. To address these problems, individual HCPAs such as FIGO, ICM, and IPA have initiated capacity building projects for HCPAs in low-resource countries in recent years (eg, the FIGO Save the Mothers initiative and the Saving Mothers and Newborns Project, and the joint UNFPA-ICM midwives program). The Society of Obstetricians and Gynaecologists of Canada (SOGC) CIDA-Funded Partnership Program aimed at the sustainable development of the technical and organizational capacity of obstetrics and gynecology professional associations in Guatemala (AGOG), Haiti (SHOG), and Uganda (AOGU) is a prime example of such activities . An important element of this program is its Organization Capacity Improvement Framework (OCIF) enabling HCPAs to measure and assess their progress in reaching their capacity building goals over time . The need to strengthen the role of HCPAs in MNCH has also been emphasized at several major meetings and in key documents, including the 2005 Multicountry Forum on Engaging the Private Sector in Child Health, the 2006 World Health Report , and the 2007 Partner's Forum. Since its inception in 2005, The PMNCH has similarly stressed the imperative need to foster stronger links across national, regional, and international HCPAs, and has the potential to provide a unique platform for uniting the HCPAs on MDGs 4 and 5. In September 2006 the HCPAs afﬁliated with the PMNCH issued a joint statement  declaring their commitment to work together and with other stakeholders on advocacy-related activities for MNCH, developing effective MNCH policies and plans tailored to national and local level needs, and capacity building of the HCPAs to improve the ability of countries to deliver quality health care.
In response to this call-to-action, the PMNCH—with the guidance of an HCPA Advisory Group and the support of the MacArthur Foundation— agreed to prepare a series of action-oriented multicountry workshops with the objective of identifying practical strategies for maximizing the contribution of HCPAs in the planning and implementation of MNCH programs and policies. The ﬁrst of these groundbreaking workshops entitled, “The Health Care Professional Associations Role in Achieving MDGs 4 and 5” was held on November 11–15, 2007, in Blantyre, Malawi and was organized principally by the ICM in collaboration with the PMNCH. This workshop assembled country delegations or “teams” consisting of HCPA representatives and senior government ofﬁcials from Ethiopia, Malawi, Nigeria, Tanzania, and Uganda. Representatives of regional and international HCPAs and other agencies also attended. The second of these workshops organized chieﬂy by FIGO in tandem with the PMNCH took place on March 26–29, 2008, in Ouagadougou, Burkina Faso and brought together HCPA and public sector representatives from Burkina Faso, the Democratic Republic of Congo, Mali, Niger, and Senegal, as well as experts from international and regional HCPAs. Full documentation of the two workshops, including participant lists and country action plans, is available at the PMNCH website: www.who.int/pmnch/ activities/healthcareprofessionals/en/index.html. Additional workshops scheduled for 2008 and 2009 will be held in Bangladesh and Bolivia, respectively. The IPA is participating in the preparation of the Bangladesh workshop.
3.2. HCPA workshop agenda and action-oriented outcomes
The format of the workshops held in Malawi and Burkina Faso was designed to be highly interactive. The ﬁrst portion of the workshops consisted of presentations and discussions on major growth areas for HCPAs, enabling participants to share and learn from each other's experiences. The remaining activities involved working group sessions during which country teams were assigned the task of developing an action plan (to be accomplished within a 1–2 year time frame) to increase the visibility of HCPAs in the planning and implementation of MNCH initiatives. Speciﬁcally, the country teams arrived at consensus about the 2 or 3 growth areas most critical to their respective countries, selected 3–5 priority actions related to these growth areas, identiﬁed obstacles to their completion, and assigned clearly deﬁned and measurable tasks to team members. Country teams also determined the support needed from the government as well as international and regional HCPAs and agencies for the successful execution of their action plans, and outlined how these plans will be implemented through partnerships between HCPAs and the public sector.
Table 1 provides an abridged version of an example of a country action plan. During the ﬁnal session, the PMNCH pledged to facilitate the achievement of the country action plans through the provision of technical support (eg, identifying potential funding sources, assisting in proposal writing, and in advocacy work to raise awareness of the needs of HCPAs), and by fostering communication across HCPAs and between HCPAs and other key MNCH stakeholders (eg, through helping with the organization of national workshops, and through establishing communities of practice via the internet). In return, the PMNCH requested that participating countries develop in-country follow-up mechanisms, and submit quarterly reports documenting successes and challenges encountered when implementing their country action plans. The workshops closed with all HCPA representatives in attendance endorsing a ﬁnal declaration of commitment to work in partnership to achieve MDGs 4 and 5.
3.3. The ﬁnal declarations: A pledge to act
The ﬁnal declarations commit workshop participants to undertake additional critical actions not included in their country action plans, and serve as a second important guide for steering activities aimed at strengthening ties between the HCPAs and ability of the HCPAs to collectively inﬂuence MNCH policy and program development. Speciﬁcally, the signed declarations hold participants accountable for carrying out concrete tasks within a speciﬁed time frame as individuals and as representatives of their respective associations. The following excerpts from the Burkina Faso declaration are illustrative:
“More speciﬁcally, we commit ourselves to the following actions, with effect from today:
- Within 6 months:
- create a coalition of HCPAs in each of our 5 countries;
- organize a meeting between this coalition and the Health ministers of our 5 countries;
- organize a joint meeting between the coalition of HCPAs and national representative ofﬁces of United Nations agencies, NGOs and other donor partners in our 5 countries;
- draw up national action plans.
- Within 1 year:
- reach agreement with our institutional and community-based partners on the role of HCPAs in supporting and implementing the roadmap/national strategic plan for maternal, newborn, and child health in our 5 countries;
- ensure that eachHCPA in our 5 countries has a functioning secretariat;
- draw up a list or schedule of (evidence-based) actions for inclusion in the national strategic plan formaternal, newborn, and child health in our 5 countries (with support from regional and international professional associations);
- organize an annual meeting to deﬁne and update HCPA objectives for the following year.
- Within 2 years:
- pilot test medical task shifting;
- organize a meeting to assess past AHP objectives and set fresh ones for the following year.”
The two declarations can be found on the Partnership website (www.who.int/pmnch/activities/countries/hcp_burkina/en/index. html and www.who.int/pmnch/activities/countries/hcp_malawi/en/index10.html).
Table 1 - Key directions of the Tanzania Action Plan.
1. Strengthen associations
- provide feedback to individual HCPAs about the Workshop;
- convene sensitization meetings to inform HCPAs on the need for establishing effective partnerships;
- inform the MoH about the importance of collaboration across HCPAs for achieving MDGs 4 and 5;
- build capacity in advocacy and lobbying skills; and
- organize training on advocacy skills in collaboration with international organizations.
2.Strengthen community participation
- perform audits to improve the quality of MNCH in districts with high MNC mortality levels;
- organize sensitization meetings at the community level with local leaders; and
- inform government ofﬁcials on the need to bring together all MNCH stakeholders in their jurisdictions.
3. Strengthen quality of care
- develop and update in-service and other training manuals;
- educate health care providers on customer care;
- increase training opportunities; and
- promote equity by advocating for increased remuneration especially for professionals working in remote areas.
The alarming numbers of preventable maternal, newborn, and child deaths that still occur each year are indicative of the signiﬁcant challenge the world faces to save the lives of the most vulnerable women and their young children. The HCPA multicountry workshops supported by the PMNCH are a catalytic step toward reducing these deaths by increasing HCPA capacity. The main products of the workshops, the country action plans and declarations with clearly delineated tasks to be achieved within the next 6, 12, and 24 months, will be used by HCPAs in collaboration with public sector representatives to pave the way forward.
The HCPA multicountry workshops have already proven to be a stimulus to action, with several activities planned by participating countries. A major focus of the 10th annual conference of the Ethiopian Pediatric Society held on May 30 2008 was on strengthening partnerships among HCPAs. The Ministry of Health of Mali is similarly organizing a meeting to foster better dialogue and develop a common agenda between HCPAs and other key actors in MNCH. With continued support and collective interest at national, regional, and international levels, this momentum will continue and ultimately beneﬁt the women and children health care professionals serve. The examples provided describing speciﬁc instances of when HCPAs have successfully played a leadership role in advocating for MNCH should also encouragemore HCPAs to begin actively working together to advocate on behalf of women and children everywhere.
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