Scaling-up Nursing and Midwifery Capacity to Contribute to the Millennium Development Goals

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Scaling-up Nursing and Midwifery Capacity to Contribute to the Millennium Development Goals



The Global Program of Work (GPW) is a result of a collaborative effort between WHO and its many partners. The process of development of this document evolved over time beginning with the 2007 Global Consultation on Strengthening Nursing and Midwifery Capacity which was hosted by the Pakistan Government (Ministry of Health) and organized by WHO in collaboration with the International Nursing Council (ICN)and International Confederation of Midwives (ICM). The follow up Consultation on Scaling-up Capacity of Nursing and Midwifery took place in Zambia, 2007, was hosted by the Zambian government and resulted in the draft Program of Work. Participants of these global consultation meetings included representative from the Aga Khan University, Nairobi, the Colombian School of Nurses Associations, Jordan University of Science and Technology, University of Kwazulu Natal, International Council of Nurses, Nightingale Initiative of Global Health, Lusaka Schools of nursing and midwifery, General Nursing Council of Zambia, the Global network of WHO Collaborating Centre on Nursing and Midwifery Development; WHO Collaborating Centre on Nursing and Midwifery Development, Kigali Health Institute, Canadian International Development Agency, University of Nottingham, (Faculty of Medicine and Health Sciences), the University of Zambia School of Medicine and Post Basic Nursing, University of South Africa, United States Agency for International Development(USAID), Canadian Association of Schools of Nursing (CIDA), GANES, John Hopkins International Education in Gynaecology and Obstetrics (JHPIEGO) and Zambia Union of Nurses Organizations (ZUNO). We also recognize the participation of Chief Nursing Officers from Malawi, Kenya, Uganda, Mozambique and Zambia, The WHO Regional Advisers from AFRO; WPRO and EURO and the WHO Global Advisory Group on Nursing and Midwifery Development. Prof. Dan Kaseje, Director of Tichinafra, Kenya served as the consultant to the Global Consultation in Zambia.

Further revisions of the Global Progamme of Work were based on the technical input from participants during the March 2008, Global Advisory Group on Nursing and Midwifery Development and Stakeholder meetings in Geneva on Scaling up Capacity of Nursing and Midwifery to Contribute to the Millennium Development Goals (MDGs). The support received from Professor Barbara Parfitt, Director, Global Health Development, Glasgow Caledonian University in the integration of the numerous feedback in this final version of the document is greatly appreciated.

The WHO is indebted for the support of the Pakistan and Zambian Government and the technical input of the participants of the Global Consultation Meeting , Aga Khan University, School of Nursing, Karachi, Pakistan, Registrar, Pakistan Nursing Council, Pakistan, New Zealand Nurses' Organization, Wellington, New Zealand, Indonesia Nurses Association, Faculty of Nursing, University of Indonesia, Jakarta, Indonesia, McMaster Site, Nursing Health Services Research Unit/WHO, Collaborating Centre, USA, Australian Nursing and Midwifery Council, Chief Executive Officer, Queensland Nursing Council, Conselho Federal de Enfermagem, Bairo Glória, Rio de Janeiro, Directorate of Nursing Services, Dhaka, Bangladesh SIDC Association, Lebanon, the Global Network of WHO Collaborating Centres for Nursing and Midwifery, Regional Adviser for nursing and midwifery, WPRO and EMRO and the participants of the march 2008 GAGNM , Stakeholders and the WHO Regional Nursing Advisers.




Abbreviations 4

The global situation 5

The contribution of nurses and midwives to health outcomes 8

The Challenges 9

Strengthening nursing and midwifery 10

The Global Program of Work 12

The core elements of the Global Programme of work 15

Action areas 2008-2009 16

Key deliverables 17

Action Plan 2008-2009 18

Education and training 18-20

Health service provision 22-23

Workplace environments 24-25

Capacity building in leadership(talent management) 26-28

Partnerships 29-30

Implementation of the Global Programme of Work 31

Development process of the GPW 31

Management of the GPW 31

Coordination Mechanisms 33

The Secretariat 33

The Regional Nursing Advisers 33

Country Action Group 34

Communication strategy 35 Annexes

Annex 1: Tools, Partners, resources, supporting mechanisms 36

Annex 2: WHA 59:27, WHA 59:23, Islamabad Declaration,

PHC Declaration 37

Annex 3: References 38-39

Annex 4: Further reading 40-42


AIDS Acquired Immune Deficiency Syndrome

NCD Non-Communicable Diseases

CNO Chief Nursing Officer

CoP Community of Practice

CPD Cardiac Pulmonary Disease

GAGNM Global Advisory on Nursing and Midwifery Development

GPW Global programme of Work

HIV Human Immunodeficiency Virus

HRH Human Resource for Health

ICN International Council of Nurses

ICM International Confederation of Midwives

ICT Information, Communication and Technology

ILO International Labour Organization

IMS Information Management Systems

MDGs Millennium Development Goals

MOH Ministry of Health

NNA National Nursing Association

NQR National Qualification Framework

RN Registered Nurses

PHC Primary Health Care

PPE Positive Workplace Environment

PSI Public Services International

TTR Treat Train and Retain

WHA World Health Assembly


In many countries life expectancy is declining. For example, a child born today in Japan can expect to live to age 82.6 on average, while it is unlikely that a newborn infant in Zimbabwe will reach his or her 39th birthday (Butler 2000). Worldwide, at least 30 new and re-emerging infectious diseases have been recognized since 1975 (Weiss and McMichael, 2004). Several ‘old’ infectious diseases, including tuberculosis, malaria and cholera have proven unexpectedly problematic. Mortality rates among children are increasing in parts of sub-Saharan Africa (Horton, 2004). Diarrhoeal disease, acute respiratory infections and other infections continue to kill more than seven million infants and children annually (Bryce et al., 2005). Ten and half (10.5) million children under five years of age die each year, 60% are preventable. Each year nearly 3.3 million babies are stillborn, and over 4 million die within 28 days following birth (WHO 2005). It is also estimated that 529,000 maternal deaths occur every year, almost all of them in developing countries (WHO 2005). In the count down to 2015, 68 priority countries that bear the world's highest burden of maternal and child mortality have been identified. Twenty six (38%) of these countries have made insufficient progress in reducing child mortality in 2008 and another 26 (38%) have made no progress at all (UNICEF et al 2008).

Noncommunicable diseases also represent a global challenge to health care systems (WHO, 1999). The increase in life expectancy beyond 60-65 years is characterized by an increased share of diseases and deaths caused by non-communicable diseases (NCD). About three-fifths of older persons reside in the developing countries. These countries already carry the greater burden of disease and have the lowest density and expertise of health workers. (UN 2000). It will require additional health care professionals with a special body of knowledge to provide the complex range of care needed by older persons. (Butler, 2002a).

In 2000, the United Nation (UN) Member States agreed on eight Millennium Development Goals (MDGs), with targets to be achieved by 2015. Of the ten MDGs, eight are related to health (UN 2001). These include eradicating extreme poverty and hunger, reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other infectious diseases (WHO 2003). Many of the MDG targets are already in jeopardy while the inequalities in health status and access to health services persists worldwide.

The ability of health care systems to respond to these rapidly evolving challenges, to maintain and improve quality, efficiency and equity of services, remains dependent on appropriately trained and supported health workers – available where and when they are needed (WHR 2006, UNAIDS, 2003, WHO 2001). Generally there is a worldwide chronic shortage in well-trained, well educated health workers including nurses and midwives (McCourt and Awases 2007). Major imbalances have been noted in health workforce structure including overall supply and demand; specialization by type; geographic distribution, institutional, public private and gender and ethnic imbalances., (Gupta, Zun, Diallo & Dal Poz, 2003; Wyss, 2004; Fritzen, 2007).

There is a two fold issue in relation to the supply of nurses and midwives worldwide. In some regions there is an over production of nurses but the scope of education is at the secondary level and their contribution to care is limited affecting their ability to meet the complex needs of the population (WHO 2006). In other regions there is an absolute health workforce shortage experienced in 57 countries, 37 of which are from Africa (World Health Report 2006; Buchan, J. and Calman L. 2004). The low availability of nurses and midwives in many developing countries is exacerbated by geographical maldistribution - there are not only fewer nurses available in rural and remote areas but in many cases they are the sole provider of health care. The shortage of nurses and midwives is attributed to a broad range of issues such as, poor working conditions, non participation in decision-making, limited opportunities for career mobility, increased workload leading to external and internal migration.(WHR 2006) Nurses and midwives are leaving the profession globally. Attempts to bring them back to the health workforce often prove challenging. In Australia through the NSW Nurse recruit programme 1,647 experienced nurses were recruited since 2002 but only 1168 are still employed today (Nursing Review Feb 2008). Migration of nurses, midwives and physicians from poorer to richer or more stable countries and the international recruitment of nurses and midwives have become more prominent features in the last few years (Dovlo 2007; Wyss 2004; Buchan & O’May 1999; ICN 1999b). An Australian longitudinal study showed that the nurses level of uncertainty of staying in the job in Australia is 20-30%,Pelletier Dianne et al (2005), which fits into the migration patterns. It is therefore necessary to design strategies that will close the gaps in wages and opportunities and thus encourage retention following recruitment and training (Staiger, Auerbach & Buerhaus, 2000; Diaz-Bonilla, Babinard & Pinstrup-Andersen, 2001; ICN, 1999a).

Yet still, in some countries, the loss of health care workers in is attributed to deaths resulting from HIV/AIDS (Stillwell 2001). In places where HIV prevalence is 15%, it is estimated that there will be up to 33 % loss of health workers in 10 year (WHO 2006). Emerging evidence also shows that the vast majority of the nursing and midwifery workforce is aging (WHO 2006). In order to address this shortage an estimated 2.3 million doctors, nurses and midwives are required to strengthen health systems and accelerate progress towards attaining the MDGs (WHO, 2006). It is pertinent therefore to consider how approaches to care based on the available human resources within the context of Primary Health Care (PHC) can be strengthened.

Primary Health Care provides an important entry point for strengthening health systems. Nurses and midwives can be catalysts of health interventions as they are central to any PHC system and they provide the leadership in managing the system. Given the pivotal role that nursing and midwifery play within the PHC system, their expertise should be called upon to enhance health service efficiency and effectiveness. Nursing and midwifery interventions are close to client and thus provide a platform for scaling up innovative health interventions. However, to strengthen their contribution as well as retain them in this area of services, there is need to place appropriate strategies. One of the recommendations from the 6th February, 2008, Chiang Mai Declaration on Nursing and Midwifery for Primary Health Care, indicates that:

"……..Employers, public and private, ensure that nurses and midwives are well remunerated, motivated by adequate incentives, and supported by safe and well equipped working environments to enhance workforce productivity and retention…..(and that) Governments commit sufficient resources to strengthen and upgrade nursing and midwifery education and practice; workforce deployment and development; and improved working conditions for nurses, midwives and other health team members, to ensure better-performing PHC systems, thereby ensuring equitable access of PHC to all".

This is in line with Dr Margaret Chan, Director General, WHO ideals "We must stay in our core business….I think it is important that we have a shared vision, that we can add value and that we can get synergy from all these partnerships…….What is important to me is, are we getting the results that matter? Are we doing the right things to make an impact on the health of the populations that we are serving? These questions have to be asked.(WHO 2007)


Studies continue to show that nurses and midwives contribute to improved access to health services and better health outcomes. In the African region over 50% of all health workers are nurses and midwives. In some countries it is as high as 70% (WHO AFRO, Observatory, 2006). In order to optimize their contribution, the education and deployment of adequate numbers of nurses and midwives with an appropriate mix of skills and competencies requires, strong effective leadership and sound strategic human resources for health long-range planning and commensurate financial investment are critical.

The biggest burden of care is shouldered by nurses and midwives, being at the first and last points of contact (Armstrong 2000). What is currently evident is that safe, proven and reasonable interventions are not reaching those in need and that clients or patients with unmet needs are disproportionate to those with lesser means. The health outcome benefits experienced by individuals, families and communities during their encounter with the health system are reduced as a consequence of the current shortage of nurses and midwives. Furthermore, in most countries health services are disease rather than customer driven characterized by limited patient voice in treatment decisions, lack of privacy or protection of dignity compounded by high or unaffordable health costs

Involving nurses in policy development and priority programmes intervention can contribute to the achievement of the Millennium Development Goals. Initial findings of a WHO study aimed at highlighting the health workforce contribution to achievement of the MDGs shows that nurse density is the primary driver for lower levels of HIV rates even when physician density is higher (Madigan et al 2007). In acute care, hospitals with higher proportions of nurses educated at baccalaureate level or higher, experienced lower mortality by 5% and failure-to-rescue rates (Aiken et al, 2003). While midwives are the principal providers for 75% of all European births, the focus on child birth as a normal event has allowed nurses and midwives to address more than just the medical aspects of childbearing (Gabay M & Wolfe SM, 1997).

In developing countries, nurses deliver over 80% of the care, often working in remote clinics with poor or no access to the latest health information (ICN 2004). Trained nurses and midwives deliver approximately 80% of health care and up to 90% of the paediatric care currently provided by primary care physicians at equal or better quality and lower costs. Under utilization of nurse practitioners in the USA cost the country as much as $8.7 billion annually (Tornquist 19997). A recent study showed that nurses and midwives as frontline workers compensate for the shortcomings of the health systems by way of individual adjustments at times to the detriment of their own health and livelihoods. This consequently serves to replicate the inequities in the health workforce ( George A. 2008). Such a finding necessitates the need to address impingements in the delivery of nursing and midwifery services to enhance the contribution of nurses and midwives.


Nurses and midwives receive little or no support and are often underutilized and excluded in the decision making processes. Critical shortages lead to overwork and little opportunity for knowledge and skills update (WHO 2006). In order for nurses and midwives to maximize their contribution there are a number of challenges that have to be addressed. These include the;

  1. provision of quality education and effective health service delivery.

  2. management and retention of the workforce

  3. motivation of nurses and midwives

  4. establishment of effective team work and collaborative partnerships

  5. recognition and management of the talent (skill sets) of nurses and midwives

The above challenges are exacerbated by inadequate policies and planning practices, lack of training opportunities, poor deployment and utilization of staff, insufficient management of performance and terms and conditions of work (Dussault, & Dubois, 2003). The focus of the human resource management required to meet these challenges should be on skill mix as well as policies and conditions that enhance the application of nursing and midwifery skills.


The 2001 World Health Assembly (WHA) Resolution on strengthening nursing and midwifery was key to the development of the Strategic Directions for Nursing and Midwifery services (2002-2008). The Strategic Directions on Strengthening Nursing and Midwifery is a sound global response to the crisis and challenges presented above, towards the achievement of global, regional and national health goals. In the 2006 Resolution (WHA59.27) on strengthening nursing and midwifery, Member States reiterated the recognition of the crucial contribution of nursing and midwifery professions to health systems and to the people they serve. This resolution clearly advocates the need for Member States to;

  1. develop comprehensive programmes on the recruitment and retention of nurses and midwives including improvements in working conditions

  2. involve nurses and midwives in the development of their health systems and in framing, planning and implementing health policies at all levels

  3. review legislation and regulatory processes relating to nursing and midwifery

  4. generate core data as part of national health information systems

In addition, Resolution WHA59.23 on Scaling-up the production of the health workforce gives further support for a strengthened of nursing and midwifery. The Islamabad Declaration 2007 on strengthening capacity of nursing and midwifery operationalized the WHA Resolutions on strengthening nursing and midwifery. This Declaration is founded on the belief that efficient, effective nursing and midwifery services are critical to the achievement of the Millennium Development Goals, country priority programmes including primary health care, health systems strengthening and the general health of all nations. The Declaration reiterates that all people should have access to competent nurses and midwives who provide care, supervision and support in all settings and that a coordinated, integrated, collaborative, sustainable approach to planning, policy and health care delivery is necessary to strengthen nursing and midwifery services. Three key action areas identified within the Declaration were ;

  1. scaling up nursing and midwifery capacity

  2. skill mix of existing and new cadres of workers

  3. positive workplace environments.

Based on these mandates, the Office of Nursing and Midwifery, Department of Human Resources for Health, WHO has spearheaded the development of an action framework for the operationalization of these resolutions and Declarations on strengthening nursing and midwifery. As WHO moves forward with innovative strategies designed to respond to human resources for health, it is essential, that nursing and midwifery expertise be viewed as a resource critical to shaping and supporting more effective health reforms, consequently strengthening the health system. Without nursing and midwifery it will be difficult to reach the MDG targets such as effectively responding to HIV/AIDS, maternal and Child health, malaria and tuberculosis.

Critical to the development of global strategies is engagement of key partners and stakeholders. To achieve this, WHO conducted a Global Consultation in December 2007 in Lusaka Zambia in the scaling up capacity of nurses and midwives. The consultation identified scaling up capacity for nursing and midwifery as a priority intervention and drafted the Global Programme of Work for 2008-09. The Programme of Work (GPW) comprises five core elements, a) education and training, b) health service provision, c) workplace environments, d) talent management, e) partnerships.


The Global Programme of Work sets out a comprehensive agenda for action on strengthening nursing and midwifery capacity to contribute to the achievement of MDGs. As a common framework and plan it seeks to kick start the scaling up of nursing and midwifery across the world during the next two year period 2008-09. Primary health care health systems which are founded on the principles that provide the basis for health policies, legislation, evaluation, criteria, resources generation and allocation and the operation of the health system (WHO/PAHO 2007, WHO1988). Social values of PHC systems include responsiveness to people’s needs, quality oriented services, government accountability, social justice, sustainability and civic participation (WHO/PAHO 2007, WHO1988). These are the premises of this action plan in the this GPW. The Action Plan comprises five core elements on scaling up capacity for nursing and midwifery for effective service delivery.

The Programme of Work on scaling up capacity of nursing and midwifery is built on the WHO resolutions, the Islamabad and Kampala declarations, the 2006 World Health Report, the WHO programme of work, the HRH work plan and the agenda for Global Action. For nursing and midwifery.

Overall Objective

The overall objective of the Global Programme of Work is:

To strengthen and facilitate mechanisms for scaling up nursing and midwifery to contribute to the achievement of the MDGs.

Objectives of the Global Programme of Work

The objectives of the GPW are to :

  1. gain political commitment to the implementation of the GPW

  2. improve quality and increased access to primary health care services at country level

  3. develop global policies, norms, standards developed for strengthening nursing and midwifery

  4. provide solutions identified based on evidence-based policies and practices

  5. establish consensus among partners through relevant mechanisms to support nursing and midwifery

  6. provide targeted technical support to WHO regions and Member States based on the needs and priorities of the population.

The objectives are to be achieved through a collaborative concerted effort by WHO and partners with the ultimate goal of achieving better health. This process is depicted in Fig. 1.

Figure 1: Global Better Health Outcomes

Strengthened Health Services (Primary Health Care)

Resources ( technical, manpower and financial)

Mainstreaming of nursing and midwifery programmes


Adequate nos. of competent tutors to support scaling-up production of nursing and midwifery workforce

PHC accessible in areas of greatest health needs

Productivity and retention of nursing and midwifery workforce increased

Leadership and management skills strengthened in support of nursing and midwifery PHC services

Global Programme of Work

Core elements

  • Education and training

  • Health service provision

  • Workplace environments

  • Talent Management

  • Partnerships


The Global Programme of Work comprises 5 core action areas:

  1. Education and training

  2. Health service provision

  3. Workplace environments

  4. Talent Management

  1. Partnerships

These core elements are interlinked and they provide a foundation for scaling up capacity of nursing and midwifery.

7. ACTION AREAS 2008-2009

For each of the core elements a brief description is provided in the table below.



Education and training

This core element will promote adequate numbers of competent educators and trainers to achieve the scaling up of competent nursing and midwifery workforce for PHC . It will specifically

address issues and solutions relating to the shortage of nurse educators, quality of education and training introduction of Global Standards and upgrading of infrastructure and increase of resources

Health Service Provision

This core element translates best practices and knowledge into practical solutions for increasing the productivity of nursing and midwifery workforce in a multidisciplinary, collaborative provision of health services in PHC settings.

It will

address the importance of the active engagement of nurses in policy decision making and the implementation of PHC. It will also highlight the necessity for nurses and midwives to carry out research and collate experiences that will provide an evidence for effective PHC practice

Workplace Environment

This core element will focus on retention of the nursing and midwifery workforce in the areas of greatest health needs with particular attention given to positive working environment.

Work will include the development and implementation of a regional nursing and midwifery policy framework based on Islamabad Declaration and ILO convention 149, and recommendation 157 to ensure healthy workplaces and organizational structures that would strengthen the performance and promote retention of nurses and midwives, maximize the health and wellbeing of nurses and midwives, thus improving workforce productivity and access to quality health care

Talent Management

This area of work will pilot key strategies for strengthening leadership, management and supervisory skills in support of nursing and midwifery workforce for PHC

Emphasis will be on developing mechanisms and implementation of strategies on skills development, career structures, continuing education and equipping nurses leaders with essential competencies for effective management and leadership roles.


This area of work supports nursing and midwifery efforts to work with multidisciplinary team and build strategic alliances through diverse partnerships in achieving PHC goals.

Through this core element, partnerships are seen as key ingredient to effective mobilization of sufficient resources and delivery of interventions on scaling up capacity of nursing and midwifery contributions to PHC. Twining, networking bilateral and global collaboration will be created and nurtured.
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