Human Resources for Health in Maternal, Neonatal and - HRH ...

although supplemented with epidemiological evidence is weak due to a lack of RCTs and
rigorous implementation studies and the reliance on descriptive and project evaluation studies
(ten Hoope-Bender, Liljestrand et al. 2006).
Despite past experience illustrating the importance of community based HR practice for
MNRH there is a trend towards facility based births. This has led to some improved outcomes
(Stanton, Blanc et al. 2007) however it has been accompanied by the under investment in
SBA at the community level and EOC. In Thailand this has led to the medicalisation of births
with the majority taking place in hospitals and a 28% caesarean rate. Professional midwifery
associations ceased to exist in the 1990s (Van Lerberghe 2001).
What is clear from the experiences of countries who have made progress towards MDG5 is
that midwives and other health workers at the community level contribute to delivery of
essential primary and reproductive healthcare and can deliver many of the needed
interventions to address maternal and neonatal mortality (Campbell and Graham 2006).
Continued investment is therefore necessary along with key HRH practices that emphasis
partnership with the community, teamwork across cadres and sectors, professional practice
and standards and sustained political and national support.
Scaling up Experiences
Scaling up refers to the transfer of knowledge from successful pilot or demonstration projects
to larger public sector programmes and into policy with the aim of increasing impact, reach
and sustainability of interventions at district, national or regional level. The literature that
discusses scaling up HRH in MNRH at community level emphasises increasing SBA
coverage, increasing the role of CHWs, expanding education and training interventions and
other approaches such as the introduction of new cadres. There are few examples where
nations have applied HR strategies that have been successful in a small number of settings to
other community settings. This may be due to the perceived difficulty of such ventures and
the high percentage of scale up efforts that fall short of expectations. These are largely the
result of a lack of supportive communication, incentives and leadership (MSH 2007 ). In
addition funding shortages have not enabled small pilot projects to be taken to scale. HRH
scale up is particularly complex as it requires significant change and financial investment.
There are many suggested models, guidelines and approaches to scaling up but much is
untested.
Rigorous evaluations of scale up efforts are also largely unavailable. Simmons et al point out
that this has not been an area regarded as worthy of research with the results of many projects
being relegated to the grey literature (Simmons, Brown et al. 2002). The authors urge project
planners and evaluators and policy makers to consider scale up possibilities as part of routine
practice allowing the consideration of these issues from the outset.
Models and approaches of scaling up
The models and approaches that are recommended as ways forward for scaling up do not all
take HRH issues into consideration nor is the community level and MNRH a focus. However
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