The Key to Progress: Health Workforce Lessons from the Family Planning Movement
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One of the great privileges of my life has been to know bold leaders in family planning and reproductive health. As I listen to the current debates about “task shifting” and “task sharing,” I am reminded of the pioneering work of Mechai Viravaidya and Allan Rosenfield in Thailand dating back to the 1960s. Along with Chitt Hemachudha, they introduced innovative approaches to family planning that can inform our current efforts to improve the health of women and their families.
The situation in Thailand at that time was similar to that faced today by many countries with a health workforce crisis. The number of doctors was quite low and they were very inequitably distributed; this meant that in large swaths of the country the doctor-patient ratio was on the order of one doctor per hundred thousand people. The Thai government had become committed to reducing the rate of population growth and improving maternal and child health. This led to the obvious conclusion that a diverse set of providers would be needed to make family planning widely available. As a result, many more types of providers were integrated into family planning education and service delivery, including nurses, midwives, auxiliary midwives, male health educators, and even shopkeepers. Many thousands of workers were trained to delivery contraceptive education and services. Training, transportation, and management were adapted to create a supportive environment for a diverse health workforce. The outcome was that Thailand was able to lower its population growth rate dramatically, and the country is often cited as a model.
The many successes of the family planning movement are grounded in adapting to the realities of a constrained health workforce. Careful testing showed that contraceptive services could be provided safely and effectively by a wide array of providers in many different settings. This vastly increased access to family planning. As much as or more than contraceptive technology, it has been creative approaches to training, deploying, managing, and supporting an increasingly diverse set of health workers that has been at the heart of the family planning movement. In recent years, Rwanda provides a sterling example of how expanding access to health workers can help drive major gains in health, including use of contraception.
Rosenfield, who later became dean of Columbia’s Mailman School of Public Health, was a major figure in maternal and reproductive health over the last four decades. He and Deborah Maine galvanized attention on maternal mortality in their famous article, Where is the M in MCH? Here, again, the health workforce issue is the key to progress. Obstetrical emergencies are the proximate cause of maternal mortality. This demands that women have access to health care workers who have the skills and supplies to manage obstetrical emergencies. It is now beyond question that the skilled birth attendant is the central figure in the fight to save women’s lives.
Over 200 million women have an unmet need for family planning. Despite recent gains, hundreds of thousands of women die unnecessarily from complications of pregnancy and childbirth. Closely linked to inadequate maternal health care are the millions of stillbirths and neonatal deaths.
Continued progress in these areas can only be achieved if skilled health workers are present. It is no accident that the countries plagued by high unmet need for family planning, low contraceptive prevalence, and high maternal and newborn mortality are also those with the worst access to skilled health workers.
Now is the time for the reproductive health advocates and health workforce advocates to join forces. The reality is that the goals of the reproductive health movement cannot be achieved without increased access to health workers, especially among the poor, the vulnerable, and those living in rural areas. Let us remember the lessons learned from the great figures in the family planning movement, like Allan Rosenfield and Mechai Viravaidya. Thanks to their work, much has been learned about rapidly scaling up the number of health workers, developing new kinds of health workers, making best use of health workers through task sharing, and supporting health workers so they can serve their communities. Building on this rich history to address the health workforce crisis is the essential step to better reproductive health.
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