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

community-based maternity-care delivery system. In this study maternal mortality decreased
in intervention sites where number of skilled attendants increased, together with development
of a referral chain and basic essential obstetric care (BEOC) facilities (Ronsmans 1997). The
challenge is to retain a balance between ensuring access to care at community level where it
is difficult to attract and retain staff and providing links to expensive tertiary facilities that
require highly trained and well paid cadres.
Figure 34 Potential gain in percentage of skilled care at delivery under six scale up options:
MW=midwife. MA=midwife assistant (Koblinsky, Matthews et al. 2006)
This modelling and the experience of countries highlight the need for the scale-up of SBA
care and services at community level to be driven by evidence gathered through monitoring
and evaluation. As each community is unique scale up options should be easily modifiable to
suit each context. The costs and benefits of scaling up should be weighed up for each location
in comparison to other approaches, such as facility-based birth care.
Scaling up other workers at community level
The need to be sensitive to context in scaling up endeavours is also central to the success of
CHW programmes. However Sundararaman (2007) points out the enormous difficulties in
gathering data concerning the scale up and sustainability of programmes such as the Mitanin
initiative in India. Evaluation of selection, training of Mitanins and community mobilisation
activities was undertaken but community baselines, controls or sufficient sample sizes were
not available to measure success against. In addition the diverse training, roles and working
environments of CHWs can lead to a range of outcomes. A number of countries have
grappled with these issues and successfully scaled up care and services at community level.
These experiences can provide guidance for others.
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