Systemic structural gender discrimination and inequality in the health workforce: theoretical lenses for gender analysis, multi-country evidence and implications for implementation and HRH policy.

This commentary brings together theory, evidence and lessons from 15 years of gender and HRH analyses conducted in health systems in six WHO regions to address selected data-related aspects of WHO's 2016 Global HRH Strategy and 2022 Working for Health Action Plan. It considers useful theoretical lenses, multi-country evidence and implications for implementation and HRH policy. Systemic, structural gender discrimination and inequality encompass widespread but often masked or invisible patterns of gendered practices, interactions, relations and the social, economic or cultural background conditions that are entrenched in the processes and structures of health systems (such as health education and employment institutions) that can create or perpetuate disadvantage for some members of a marginalized group relative to other groups in society or organizations. Context-specific sex- and age-disaggregated and gender-descriptive data on HRH systems' dysfunctions are needed to enable HRH policy planners and managers to anticipate bottlenecks to health workforce entry, flows and exit or retention. Multi-method approaches using ethnographic techniques reveal rich contextual detail. Accountability requires that gender and HRH analyses measure SDGs 3, 4, 5 and 8 targets and indicators. To achieve gender equality in paid work, women also need to achieve equality in unpaid work, underscoring the importance of SDG target 5.4. HRH policies based on principles of substantive equality and nondiscrimination are effective in countering gender discrimination and inequality. HRH leaders and managers can make the use of gender and HRH evidence a priority in developing transformational policy that changes the actual conditions and terms of health workers' lives and work for the better. Knowledge translation and intersectoral coalition-building are also critical to effectiveness and accountability. These will contribute to social progress, equity and the realization of human rights, and expand the health care workforce. Global HRH strategy objectives and UHC and SDG goals will more likely be realized.

Effect of integrating maternal and child health services, nutrition and family planning services on postpartum family planning uptake at 6 months post-partum in Burkina Faso, Cote d'Ivoire and Niger: a quasi-experimental study protocol.

BACKGROUND: Although several interventions integrating maternal, neonatal, child health and nutrition with family planning have been implemented and tested, there is still limited evidence on their effectiveness to guide program efforts and policy action on health services integration. This study aims to assess the effectiveness of a service delivery model integrating maternal and child health services, nutrition and family planning services, compared with the general standard of care in Burkina Faso, Cote d'Ivoire, and Niger. METHODS: This is a quasi experimental study with one intervention group and one control group of 3 to 4 health facilities in each country. Each facility was matched to a control facility of the same level of care that had similar coverage on selected reproductive health indicators such as family planning and post-partum family planning. The study participants are pregnant women (up to 28 weeks of gestational age) coming for their first antenatal care visit. They will be followed up to 6 months after childbirth, and will be interviewed at each antenatal visit and also during visits for infant vaccines. The analyzes will be carried out by intention to treat, using generalized linear models (binomial log or log Poisson) to assess the effect of the intervention on the ratio of contraceptive use prevalence between the two groups of the study at a significance level of 5%, while taking into account the cluster effect and adjusting for potential confounding factors (socio-demographic characteristics of women unevenly distributed at inclusion). DISCUSSION: This longitudinal study, with the provision of family planning services integrated into the whole maternal care continuum, a sufficiently long observation time and repeated measurements, will make it possible to better understand the timeline and the factors influencing women's decision-making on the use of post-partum family planning services. The results will help to increase the body of knowledge regarding the impact of maternal and child health services integration on the utilization of post-partum family planning taking into account the specific context of sub-Saharan Africa French speaking countries where such information is very needed.

One strategy to improve the utilization of health services by mothers and their children is the integration of maternal and child health services. For instance, a pregnant woman coming for an antenatal care visit would also receive counseling on post-partum family planning services and maternal nutrition. Similarly, a woman coming for her infant's vaccines would be offered counseling on post-partum family planning, maternal nutrition and breastfeeding. Although several interventions have been implemented and tested, there is still limited evidence on the conditions and factors required for successful maternal and child health services integration strategies. This study aims to assess the effectiveness of an intervention integrating maternal and child health services, nutrition and family planning services. For the purpose of the evaluation, 2 distincts groups of health facilities will be selected in each country, one group of 3 or 4 health facilities where the intervention will be implemented, and another group of 3 or 4 health facilities with the general standard of care. The study participants are pregnant women (up to 28 weeks of gestational age), coming for their first antenatal care visit, who will be followed up to 6 months after childbirth.The analyzes will be carried out to assess the effect of the intervention on contraceptive use prevalence between the two groups of health facilities. This study will make it possible to better understand the timeline and the factors influencing women's decision-making on the use of post-partum family planning services.

Accreditation of private midwifery and nursing schools in Mali: a local sustainable solution to increasing the supply of qualified health workers.

BACKGROUND: The World Health Organization's Global Strategy on Human Resources for Health (HRH) emphasizes the importance of dynamic and effective health worker regulation for achieving the health-related Sustainable Development Goals, with the establishment of education standards and quality assurance of education programs being critical. Governments in West Africa have struggled to address the problems within their higher education systems for health professionals, and it is now generally acknowledged that private institutions can play a crucial role in revitalizing the region's outdated universities. However, the rapid expansion of private schools raises concerns about the quality of education and adequacy of regulatory mechanisms. The USAID-funded Mali HRH Strengthening Activity, led by IntraHealth International, assisted Mali's Ministry of Health and Social Development to deliver targeted HRH interventions to improve the quality of education in private universities, better manage available health workers, and initiate a decentralized strategy for health worker recruitment and motivation. CASE PRESENTATION: In 2018, the HRH activity leveraged the West African Health Organization (WAHO)'s accreditation system to support 10 private nursing schools to introduce WAHO's regionally accepted, competency-based curriculum in reproductive, maternal, newborn, and child health. The project undertook a 10-step process to work alongside private nursing and midwifery schools to assess their current status against WAHO regional standards, implement action plans to address identified gaps, and support the institutions toward accreditation. As a result, eight schools in Mali are now accredited compared to only three at project inception. CONCLUSIONS: This case study underscores the importance of private school accreditation in Mali to improve the quality of health worker training through a standardized local curriculum. By supporting existing regulatory bodies that oversee accreditation, local capacity for initial accreditation of private nursing schools has been increased. Engaging universities in a partnership that shows the benefits of accreditation while maintaining a focus on the need to protect communities is critical to success. If the global community is to meet the WHO's predicted health worker shortfall, then private education providers will need to be part of the solution. Robust and engaging health worker education accreditation systems are an essential part of that future.

Increasing Contraceptive Use Through Free Family Planning Special Days in Poor Urban Areas in Francophone West Africa.

INTRODUCTION: In francophone West Africa (FWA), contraceptive uptake remains limited, often due to geographic, economic, and social barriers. With technical support from The Challenge Initiative (TCI), municipalities and health systems implemented Family Planning Special Days (FPSDs) to improve family planning (FP) uptake and reduce high unmet need. The FPSD intervention consisted of organizing free FP services on a monthly or quarterly basis over 2 to 5 consecutive days within health facilities or sites close to the population. These events helped to educate, inform, and mobilize the community around FP and improve geographic and financial access to FP services. We describe the process of implementing FPSDs in FWA countries and analyze the results. METHODS: We used several techniques and data sources in our descriptive analysis, including document review of activity reports, analysis of health management information system data, and retrospective data collection on the profile of FPSD users and implementation costs. RESULTS: Between July 2020 and June 2021, municipalities and health systems collaborated to hold 1,046 FPSDs in 452 health facilities in 10 FWA cities. This collaboration was made possible through the establishment of city-level management and coordination units composed of municipal, health system, and TCI focal points. In the 10 FWA cities, 181,792 people were made aware of the FPSDs and 71,669 contraceptive users were served. The overall cost of organizing the FPSDs was about 145382501 Central African CFA francs (US$252839), 35% of which came from the municipalities' local financial contribution. DISCUSSION: Results from our analysis showed that, with appropriate financial support from municipalities, the health system could offer high-quality free FP services. Nonetheless, there are still challenges to the sustainability of conducting FPSDs, including the availability of contraceptive products and continued financing of the strategy during system shocks such as the COVID-19 pandemic.

Assessment of Staffing Needs for Frontline Health Workers in Selected Maternal and Child Health Services in 3 Countries of Sub-Saharan West Africa: Cote d'Ivoire, Burkina Faso, and Niger.

Sub-Saharan African countries health systems are generally faced with shortages and inequitable distribution of qualified health workers. The application of provider-population ratio or fixed staff establishments, not considering variation in workload, given contextual variations in service utilization rates, cannot adequately match the human resource needs of different health facilities. The Workload Indicators of Staffing Need (WISN) method uses workload to determine staffing needs in a given facility. The aim of this study was to assess the current workload and staffing needs of maternal and child health services in 12 primary healthcare facilities from Burkina Faso, Niger, and Cote d'Ivoire. We employed the WISN methodology, using document reviews, in-depth interviews with health providers, and observations, to obtain the data needed for estimating the required number of staff in a given facility. Then, we calculated both the WISN difference (current-required staff), and the WISN ratio (current staff/required staff). Using the WISN ratio, we assessed the work pressure that health workers experience. The results showed a shortage of health workers in most services in Cote d'Ivoire and Niger (WISN ratio <1), in contrast to Burkina Faso where services were either adequately staffed or overstaffed (WISN ratio ⩾1). The workload pressure was generally high or very high in Cote d'Ivoire, while in Niger, it was very high in maternity services but rather low in dispensary ones. There was also a geographic discrepancy in health workers staffing, rural areas services being more understaffed, with a higher workload pressure as compared to urban areas ones. This study results strengthens the body of knowledge on the shortage of health workforce in sub-Saharan Africa French speaking countries. Policies and strategies to increase students training capacities and the application of regular WISN studies for a better staff distribution are necessary to address the human resource needs of health facilities in these countries.