Developing strategies to attract, retain and support midwives in rural fragile settings: participatory workshops with health system stakeholders in Ituri Province, Democratic Republic of Congo.

BACKGROUND: Midwifery plays a vital role in the quality of care as well as rapid and sustained reductions in maternal and newborn mortality. Like most other sub-Saharan African countries, the Democratic Republic of Congo experiences shortages and inequitable distribution of health workers, particularly in rural areas and fragile settings. The aim of this study was to identify strategies that can help to attract, support and retain midwives in the fragile and rural Ituri province. METHODS: A qualitative participatory research design, through a workshop methodology, was used in this study. Participatory workshops were held in Bunia, Aru and Adja health districts in Ituri Province with provincial, district and facility managers, midwives and nurses, and non-governmental organisation, church medical coordination and nursing school representatives. In these workshops, data on the availability and distribution of midwives as well as their experiences in providing midwifery services were presented and discussed, followed by the development of strategies to attract, retain and support midwives. The workshops were digitally recorded, transcribed and thematically analysed using NVivo 12. RESULTS: The study revealed that participants acknowledged that most of the policies in relation to rural attraction and retention of health workers were not implemented, whilst a few have been partially put in place. Key strategies embedded in the realities of the rural fragile Ituri province were proposed, including organising midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and thus generate more income; lobbying non-governmental organisations and churches to support the improvement of midwives' living and working conditions; and integrating traditional birth attendants in health facilities. Contextual solutions were proposed to overcome challenges. CONCLUSION: Midwives are key skilled birth attendants managing maternal and newborn healthcare in rural areas. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. This participatory approach through a workshop methodology that engages different stakeholders and builds on available data, can promote learning health systems and develop pragmatic strategies for the attraction and retention of health workers in fragile remote and rural settings.

Using data to support evidence-informed decisions about skilled birth attendants in fragile contexts: a situational analysis from Democratic Republic of the Congo.

BACKGROUND: Most low- and middle-income countries are experiencing challenges in maternal health in relation to accessing skilled birth attendants (SBA). The first step in addressing this problem is understanding the current situation. We aimed to understand SBA's availability and distribution in Ituri Province, North Eastern Democratic Republic of the Congo (DRC) from 2013 to 2017. METHODS: We used available data on SBAs (doctors, nurses and midwives) from the Ituri Provincial Human Resource for Health Management Unit's database from 2013 to 2017. The current distribution across and within three categories of district (rural, peri-urban and urban) and characteristics of SBAs as well as 5-year trends and vacancy trends were identified. Data on training outputs for SBA cadres was collected from training schools in the province. Descriptive analysis, disaggregating by district, cadre and gender where possible, was conducted using Excel. RESULTS: The national ratio of SBAs per 1000 population is four times less than the Sustainable Development Goals threshold (4.45) while the Ituri Province ratio is one of the lowest in DRC. There are more doctors and nurses in urban and peri-urban districts compared to posts, and shortages of midwives in all district categories, particularly in rural districts. From 2013 to 2017, occupied posts for doctors and nurses in all three categories of districts increase while midwives decrease in peri-urban and rural districts. There is clear gender and occupational segregation: doctors and nurses are more likely to be male, whereas midwives are more likely to be female. The projections of training outputs show a surplus against authorised posts of doctors and nursing increasing, while the shortfall for midwives remains above 75%. CONCLUSION: This is the first study to use existing human resource data to analyse availability and distribution of SBAs in a DRC province. This has provided insight into the mismatch of supply and demand of SBAs, highlighting the extreme shortage of midwives throughout the province. Further investigations are needed to better understand the situation and develop strategies to ensure a more equitable distribution of SBAs throughout this province and beyond. Without this, DRC will continue to struggle to reduce maternal mortality.

'Being a midwife is being prepared to help women in very difficult conditions': midwives' experiences of working in the rural and fragile settings of Ituri Province, Democratic Republic of Congo.

INTRODUCTION: Maternal and neonatal health are core focus areas in fragile and conflict-affected areas, and hence midwives are key actors. But there is currently very little evidence on midwives' experiences, the challenges that they face and coping strategies they employ in the challenging and fragile rural areas of Ituri Province in the north-eastern part of the Democratic Republic of Congo (DRC). This understanding is critical to developing strategies to attract, retain and support midwives to provide vital services to women and their families. This study aims to explore midwives' work experiences and challenges through time from initial professional choice to future career aspiration in rural Ituri Province, north-eastern DRC. METHODS: As part of a qualitative approach, life history interviews with 26 midwives and 6 ex-midwives, and three focus group discussions with 22 midwives in three health districts of Ituri Province (Bunia, Aru and Adja), were conducted in 2017. Purposive sampling was used to recruit research participants. The transcripts were digitally recorded, and thematically analyzed using NVivo software. A timeline framework was deployed in the analytical process. RESULTS: Problem solving, childhood aspirations and role models were the main reasons for both midwives and ex-midwives to join midwifery. Midwives followed a range of midwifery training courses, resulting in different levels and training experiences. Midwives faced many work challenges: serious shortages of qualified health workers; poor working conditions due to lack of equipment, supplies and professional support; and no salary from the government. This situation was worsened by insecurity caused by militia operating in some rural health districts. Midwives in those settings have developed coping strategies such as generating income and food from farm work, lobbying local organizations for supplies and training traditional birth attendants to work in facilities. Despite these conditions, most midwives wanted to continue working as midwives or follow further midwifery studies. Family-related reasons were the main reasons for most ex-midwives to leave the profession. CONCLUSION: Midwives play a critical role in supporting women to deliver babies safely in rural Ituri Province. They face immense challenges and demonstrate bravery and resilience as they navigate the interface between underresourced health systems and poor, marginalized rural communities. This situation requires a call to action: donors need to prioritize these contexts; and the government and other stakeholders in DRC need to invest more in improving security conditions as well as working conditions and professional support for midwives in rural Ituri Province. Only then will midwives be able to provide the critical services that women and their families need, and therefore contribute to achieving universal health coverage.

Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya.

BACKGROUND: Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi's equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. METHODS: We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. RESULTS: Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. CONCLUSIONS: If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity.

Sexual and reproductive health activities in HIV programmes: can we monitor progress?

BACKGROUND: Resource allocation and integration of services have been of interest recently to achieve health-related Millennium Development Goals. This paper analyses the extent to which countries receiving funding in HIV were able to invest in activities in the area of sexual and reproductive health (SRH). METHODS: The authors screened the Global Fund grants data with an aggregate investment of US$16 billion in 140 countries to identify indicators revealing typical SRH services. The analysis focused on the 'Top Ten' internationally agreed indicators and used international guidelines and frameworks to define services for SRH and opportunities for 'linkage' between HIV and SRH services. RESULTS: As of December 2008, 238 of all HIV grants (n = 252) from 133 countries included 1620 service delivery indicators related to SRH. The budgets amounted to US$9.1 billion with US$5.9 billion committed and US$4 billion disbursed. Services included (1) prevention of mother to child transmission for 445,000 HIV-positive pregnant women, (2) 5.7 million care and support services, (3) 1.2 billion condoms delivered, (4) 4.4 million episodes of sexually transmitted infections treated, (5) 61 million counselling and testing encounters, and (6) 11.6 million behavioural change communication (BCC) outreach services for people at high risk and 64.5 million BCC activities for the general population, including youth. Information on the linkage and integration of SRH-HIV services was limited. CONCLUSION: Around 94% of HIV programmes supported SRH-related activities. However, there is a need to systematically capture data on SRH-HIV service integration to understand the benefits of linking these services.