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

Outlawing TBA practice for example in rural Costa Rica may have improved maternal
mortality but it also affected links with the community and led to loss of cultural support
approaches (Jenkins 2003).
One of the barriers to the successful shifting of tasks to lower cadres such as moving the
responsibility of injecting contraceptive to CHWs has been a lack of both a regulatory
framework and proper financial mechanisms to sustain it. A regulatory framework is essential
to ensure government support, protection of patients and health workers and sustainability as
well as resource flow. According to a WHO consultation the existing barriers to task shifting
must be identified and minimised (WHO 2007).
Challenging working environments
The delivery of quality care and services depends upon the support of partnerships between
members in a PHC team, or across the health care sector with state and non state providers,
cultural or traditional providers or at various levels linking the community to facilities. A
review of CHWs identified few studies that have brought out the importance of building
healthy ―inter-relationships‖ and ―trust‖ among health professionals in building an effective
feedback and referral systems in place (Prasad 2007). There are however a number of studies
that have highlighted various problems in teams and partnerships.
Poor PHC team work has been found to be affected by low levels of HR trust in CHWs which
has led to poor intersectoral collaboration (Sauerborn 1989; Cruse 1997). Midwife and nurse
cadres attitudes towards CHWs and TBAs has been documented as disrespectful (Iyun 1989;
Replogle 2007) and paternalistic (Walt, Perera et al. 1989) which contributes to poor
communication and the perceived low status of these cadres (Walt 1990; FIGO 2009). Low
levels of traditional and biomedical collaboration have been documented particularly between
midwifes and TBAs (Kaboru 2006). In Indonesia this is affected by competition between
midwifes and TBAs (Utomo 2008).
The socio-cultural context of the community can pose a number of challenges to health
workers. Authors have outlined a number of gender-based barriers to primary health care
provision in Pakistan which includes harassment of female workers and the imposition of
conditions on their practices such as the need to be accompanied by a male relative (Mumtaz,
Salway et al. 2003). Health workers at community level may also face challanges delivering
services that deal with sensitive issues that may not normally be discussed or are not
acceptable. For example a survey of the status of community-based postpartum care and
postpartum family planning services implemented by MotherNewBorNet member
organizations in the Asia Near East region found that health care workers in some contexts
are afraid to discuss family planning with some clients because of fear that they will tell their
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