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Scoping Analysis on LHV and MW Future Career Prospects

September 2018 20 – 26 December 2018

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Acknowledgements

With close collaboration and cooperation between the Department of Human Resources for

Health (HRH), Ministry of Health and Sports (MoHS), and Jhpiego- Johns Hopkins University

Affiliate, a “Scoping Analysis on LHV and MW Future Career Prospects” was conducted. This was

funded by the 3MDG.

First and foremost, we are greatly indebted to the MoHS for their guidance and leadership for

the approval of analysis. Then, key stakeholders from Department of HRH, Department of Public

Health, Department of Medical Service, Myanmar Nurse and Midwife Council, Myanmar Nurse

and Midwife Association, Lady Health Visitor (LHV) School for letting the study team to conduct

Key Informant Interviews and all the LHVs and Midwives representatives who involved in the

focus group discussion and the workshop. Moreover, Jhpiego would like to extend special thanks

to Daw Htay Htay Hlaing, Director Nursing, Department of HRH and team for sharing survey data

collected from LHV students and Dr. Than Lwin Htun, Director (Health Promotion Unit),

Department of Public Health and team for sharing his BHS utilization analysis powerpoint.

Sincere gratitude is hereby extended to the 3MDG Fund for their funding support to make this analysis possible; Nursing section Department of HRH and Jhpiego technical and M&E team for supporting data collection and analysis. Lastly, Jhpiego Myanmar also wish to extend their sincere appreciations to all the people who

shared their experiences and perspectives for this scoping analysis on LHV and MW future career

prospects.

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Table of Contents

Acknowledgements ........................................................................................................................... i

Acronyms ......................................................................................................................................... v

Executive Summary ........................................................................... Error! Bookmark not defined.

Background ..................................................................................................................................... 1

Objectives........................................................................................................................................ 2

Methodology ................................................................................................................................... 3

Survey Questionnaires (Sep 2018) ........................................................................................... 3

› Total 149 LHV trainees who attended LHV training (30 Sep 2018) ......................................... 3

Key Informant Interview (KII) (20 – 26 Dec 2018) ................................................................... 3

› Total 15 key stakeholders from DHRH, DOPH, DOMS, LHV schools, MNMC and MNMA ...... 3

› KII Team ................................................................................................................................... 3

Workshop (one and half day workshop) (20 – 21 Dec 2018) .................................................. 3

› Focus Group Discussion - Total 46 participants ....................................................................... 3

› Group work and Discussions on case scenarios with LHV and MW ........................................ 3

› Workshop Facilitator Team ..................................................................................................... 4

Findings and Discussions ................................................................................................................. 4

Career Ladder and Continuing Personal and Professional Development ............................. 10

Bottlenecks to become LHV .................................................................................................. 10

Drives NOT to become LHV ................................................................................................... 11

Career ladder for LHV is not clear ......................................................................................... 11

Concerns about BMSc program ............................................................................................. 11

Concerns about future of LHV ............................................................................................... 12

Continuing Personal and Professional Development (CPPD) ................................................ 12

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Midwives and LHVs’ Scopes of Work ..................................................................................... 12

Responsibilities and Competencies ....................................................................................... 12

Roles and Responsibilities ..................................................................................................... 13

Role Conflicts ......................................................................................................................... 13

Supports and Supervision ...................................................................................................... 13

Safety and Protection ............................................................................................................ 13

Suggestions ............................................................................................................................ 13

Community Perspectives on Midwives and LHV scopes of work .......................................... 13

Difference between roles and responsibilities of MW and LHV ........................................... 14

Career Development Options for MW and LHV .................................................................... 15

Case scenario 1: Increase LHV production to fill current LHV gaps ...................................... 17

Case scenario 2: Develop Alternative Strategies to fill current LHV gaps ............................. 18

Case scenario 3: Stop production of LHV and develop the new channel as career ladder .. 19

Summary and Recommendation .................................................................................................. 20

1). Option 1: Increase LHV production to fill the current gaps ............................................. 20

Strategy 1: Increase number of LHV training school ..................................................... 20

Strategy 2: Increase number of LHV trainee intake ....................................................... 21

Strategy 3: Reduce course duration (condensed LHV course) and accept 2-3 LHV batches

per year .................................................................................................................................. 21

2). Option 2: Development alternative strategies to fill current LHV gaps ........................... 21

Strategy 4: Promote as Senior Midwife ......................................................................... 21

3). Option 3: Stop production of LHV and develop the new channel as career ladder ........ 21

Strategy 5: Stop production of LHV and develop the new career ladder as BMSc

Midwives ................................................................................................................................ 21

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Annex 1: Reference ....................................................................................................................... 23

Annex 2: Workshop Agenda (FGD and Groupwork): .................................................................... 23

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Acronyms

3MDG Three Millennium Development Goal Fund

DHRH Department of Human Resources for Health

DOMS Department of Medical Service

DPH Department of Public Health

HRH Human Resources for Health

LHV Lady Health Visitor

MNMA Myanmar Nurse and Midwife Association

MNMC Myanmar Nurse and Midwife Council

MoHS Ministry of Health and Sport

MW Midwife/ Midwives

NHP National Health Plan

NIMU NHP Implementation Monitoring Unit

NPT Nay Pyi Taw

PPT Power Point

SDG Sustainable Development Goals

UHC Universal Health Coverage

WHO World Health Organization

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Background

The National Health Plan 2017-2021 aims to strengthen Myanmar’s health system and improve

equitable access to quality essential health services and interventions for the entire population

with the longer-term goal of achieving universal health coverage (UHC) by 20301. A fit-for-

purpose health workforce is needed to achieve this goal. However, Myanmar is still facing

challenges with a shortage of human resources for health (HRH), inappropriate balance of health

worker cadres and mix of skills, inequitable geographic distribution and difficulties in retaining

health workers in rural areas.

Although the number of health workers increased and there were 1.33 health workers (doctors,

nurses and midwives) per 1,000 population in 20161, this number is still far below the SDG target

of 4.45 health workers per 1,000 population recommended by the World Health Organization

(WHO) to achieve SDGs and UHC2. The main factors influencing on HRH shortage in Myanmar

are: rate of production, deployment of health workforce, distribution across country and

retention/attrition of health workforce in the public sector. This HRH shortage is most significant

in the rural areas, where 70% of total population resides3 and basic health staff (BHS) provide

health services. In 2018, the Department of Public Health (DoPH), Basic Health Staff Section’s

analysis on BHS utilization and career ladder revealed that vacancy rate for lady health visitors

(LHV), health assistants (HA) and public health supervisors I (PHS I) are 40%, 45% and 70%

respectively and there have a huge bottleneck in the production and career ladder of LHV and

PHS I4. However, the training schools under Department of Human Resources for Health (DHRH)

have limited capacity and rate of production of LHV and PHS I per annum and there has been a

long queue to become LHV and PHS I. Within the current practice and strategies, it will at least

takes 8 years and 19 years to fill the LHV and PHS I gaps respectively in Myanmar (assuming stable

retention). In addition, due to the uncertain career prospects, Midwives and LHVs’ concerns are

raised to key stakeholders. Therefore, Union Minister for Health and Sports (MoHS) and

Department of HRH would like to gather more information on what are the bottlenecks to

become LHVs (from midwives to become LHV) and LHV’s future career prospects (LHV career

ladder) and what would be possible strategies to fill the LHV gaps within the limited resources

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and time. Therefore, Nursing Section Department of HRH team conducted survey data collection

from LHV students in September 2018 and explored students’ perspectives on career prospects.

Then, with the guidance from the Union Minister for MoHS, Director General (DHRH) and Director

(Nursing, DHRH), Jhpiego provided technical assistance and conducted scoping analysis on the

future career prospects of LHVs and their fellows midwives in December 2018.

This scoping analysis will focus on LHV and Midwives’ future career perspectives and the

workshop (Focused Group Discussions and Group Work) aims to include voices from the fields

(Lady Health Visitors, Midwives and Communities) as well as key informant interviews aim to

explore vision and perspectives of HRH key stakeholders in Myanmar.

Objectives

To explore the Vision and Perspectives of Key HRH leaderships from DHRH, DOPH and

DOMS on LHV and MW future career prospects

To explore the Perspectives of Professional Bodies (MNMC and MNMA) on LHV and MW

future career prospects

To explore the Perspectives of Key Stakeholders from LHV School on LHV and MW future

career prospects

To identify LHVs’ perspectives on their scope of work and future personal and

professional development

To find out LHV trainees’ perspectives on their scope of work and future personal and

professional development

To comprehend Senior and Junior MWs’ perspectives on their scope of work and future

personal and professional development

To explore Community’s expectation and perspectives on Primary Health Care

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Methodology

The scoping analysis was conducted based on desk reviews on the BHS utilization and career

ladder analysis conducted by Department of Public Health and then, primary data collection by

using the following quantitative and qualitative mixed methods:

Survey Questionnaires (Sep 2018)

› Total 149 LHV trainees who attended LHV training (30 Sep 2018)

Key Informant Interview (KII) (20 – 26 Dec 2018)

› Total 15 key stakeholders from DHRH, DOPH, DOMS, LHV schools, MNMC and MNMA

3 Leadership Personnel from Department of HRH 3 Leadership Personnel from Department of Medical Service 3 Leadership Personnel from Department of Public Health 2 Leadership Personnel from Lady Health Visitor School 2 Leadership Personnel from Myanmar Nurse and Midwife Council 2 Leadership Personnel from Myanmar Nurse and Midwife Association

› KII Team

Dr. Khin May Oo, Operational Research Manager Daw Nan Nan Aung, Senior Technical Advisor Dr. Toe Than Tun, Technical Advisor Dr. Kyaw Kyaw, Technical Advisor Dr. Nyi Naung Yoe, Technical Advisor Daw Shwe Sin Nay Lin, Training and Capacity Development Officer

Workshop (one and half day workshop) (20 – 21 Dec 2018)

› Focus Group Discussion - Total 46 participants

17 Lady Health Visitors from (1 LHV from each State/Region) 10 Midwives with more than 10 years of experiences 10 Midwives newly posted midwives (<2 years of service) 9 Community Representatives, who lives in NPT

› Group work and Discussions on case scenarios with LHV and MW

17 Lady Health Visitors from (1 LHV from each State/Region)

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10 Midwives with more than 10 years of experiences 10 Midwives newly posted midwives (<2 years of service)

› Workshop Facilitator Team

Dr. Khine Haymar Myint, Project Director Dr. Thida Moe, Senior Technical Advisor Dr. Hayman Nyo Oo, Technical Advisor Dr. Kyaw Za, Technical Advisor Dr. Okka Phyo, Senior Technical Officer Daw Cho Cho Myint, Training and Capacity Development Officer Daw Khin Myat Noe Oo, Monitoring and Evaluation Officer U Yan Aung, Monitoring and Evaluation Officer

Findings and Discussions

The study team conducted a desk review on the findings of Department of Public Health’s BHS

utilization and career ladder analysis4 with the emphasis on LHV. According to the analysis

results, as of 31 October 2018, there were 3143 sanctioned post for LHVs and only 1888 were

appointed, resulting 1255 vacant posts (40% vacancy rates). Table 1 describes the current

shortage of BHS with the emphasis on LHV.

Table 1: Current Shortage of BHS (Emphasis on LHV)

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When we looked at the midwives vacancies (Table 1), the vacancy are 670 posts (5% vacancy

rates) only. This might be due to adequate production of midwives as well as limited career

development (long promotion queue) to become LHVs or change into nursing profession. In

theory, it takes 2-year to become midwives and after completion of 3-year in-service, the

midwives are entitled to apply for LHV and take entrance exam. If they pass the entrance exam,

they become LHV after 9 months training. However in reality, midwives are not able to take

entrance exams soon after completion of 3-year in-service and the average waiting time to take

entrance exam is 7-10years and to become a LHV takes 10-15 years on average. Because, there

is only one LHV training school in Myanmar with the capacity of production of approximate 150

LHV per year. If the midwives would like to change the nursing profession, they can apply for

nursing bridge course and study two more years to become a nurse-midwife. Therefore, only

approximate 2-3% of midwives are either promoted to LHV or changed into nursing profession

annually and it results less vacancy rate for midwives. Table 2 and Table 3 describe Career Ladder

for Midwives and Number of midwives who attended LHV and Nursing training from 2015 to

2017.

Table 2: Career Ladder for MW

Table 3: Numer of MW who attended LHV and Nursing Training (2015 - 2017)

If MoHS keeps using this approach to produce LHV, it will take at least 8 years to fill the gap (keep

the retention as constant) and therefore, it is important and urgent priority for MoHS to find

alternative mechanisms to produce LHV or similar cadres to fill the gaps. Figure 1 illustrates time

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taken to fill the LHV gaps (based on the LHV vacancy described in Table 1 and maximum

production from LHV training school Table 3).

Figure 1: Time taken to fill the LHV gaps

Therefore, with the guidance from the Department of HRH, the study team starts explore

possible alternative strategies and innovative approaches to fill the LHV vacancy posts within

limited time and available resources. One of the possible strategies identified is to create a new

post, “Senior Midwife” and adopt the policy of “a midwife will entitle to get promotion of senior

midwives after certain number of in-service years (eg. 3 – 5 years)”. This will overcome the

bottleneck of a long queue to attend LHV training school. However, it will create challenges and

capacity gaps if senior midwives do not receive certain training or LHV training. Another possible

strategies is to increase number of LHV training schools or shorten the duration of LHV training

so that the rate of LHV production will increase per year. With these two possible approaches in

mind, the study team conducted a survey data collection at the Yangon LHV training school in

September 2018, to explore LHV trainees’ reasons for why they want to become LHV, their

impression on current LHV training program and their perspective on creating of a new post,

Ref: Table 1

Ref: Table 3

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Senior Midwife. In total, all 149 LHV trainees took part in the survey and figure 2 summarize the

reasons why they are attending LHV training.

Figure 2: Reasons for attending LHV training

Majorities, 36% of survey respondents stated that they are attending LHV training because they

would like to get promotion. 51 % of the respondents highlighted that their skills, competencies

and management skills will be strengthened if they take the LHV course and therefore, they

applied for the LHV training course.

It is interesting to find out that 90% of the responded that the major challenges of current LHV

training school is inadequte infrastrature for teaching, learning and accomodation for students.

In addition, to improve current LHV training programme, 30.9% of LHV students suggested

reducing training period and 30.1 % suggested to update the training curriculum to be in line with

evidence-based global practices. 26.5% recommended to improve school’s infrastructure for

better learning whereas 2.2% suggested opening additional LHV training schools. Figure 3 and 4

illustrate the challenges of current LHV training schools and their recommendations on improving

current LHV training programme.

Promotion, 36%

Management Skills, 18%

Upgarde Skills and

Competencies, 33%

Interested in Public Health,

9%

Others, 4%

REASONS FOR ATTENDING LHV TRAINING

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Figure 3: Challenges of current LHV Training School, Yangon

Figure 4: LHV trainee's recommendation on improving current LHV training program

In regards to creating a new post, Senior Midwife, 62% of the survey respondents agree that

creation of this post will help filling the LHV shortage gaps. However, 28% of the survey

respondents disagree based on their time and efforts to apply for LHV post and they raised the

concerned that this option might create role conflicts between senior midwife and LHVs unless

clearly define on the career prospects of LHV. The figure 5 summarized LHV trainees’ opinion on

creating Senior Midwife post.

Not enough infrastructure, 90%

Others, 10%

CHALLENENGES OF CURRENT LHV SCHOOL

30.9% 30.1%

5.1%

26.5%

2.2%5.1%

To reducetrainingduration

To updatecurriculum

To include ITskills training

To upgradefacility to

accommodatestudents

To establishmore training

schools

Others

LHV Trainees' Recommendations on Improving LHV Training Programme

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Figure 5: LHV trainee's opinions on creating a new post, Senior Midwife

If a midwife is promoted as senior midwife after certain number of in-service years without

undergoing training (eg. LHV 9-month training), there will be a number of challenges that she will

encountered in her career as senior midwife. Therefore, LHV trainees’ opinions on potential area

of challenges for a senior midwife (without additional training) was explored. The 36% of LHV

students thought that management and administrative duties and supervision (26%) will be most

striking challenges that she will encounter in the career. Lack of respect, knowledge and attitude,

role conflicts and competency issues are also selected as potential area of challenges. Figure 6

summarize these findings.

Figure 6: Potential Areas of Challenges if Sr. MW are Promoted without LHV Training

62%28%

11%

LHV Trainees' Opinions on Creating a New Post, Senior Midwife

Agree

Disagree

Not Given

3%7% 9%

36%

7%2%

7%

26%

3%

Potential Areas of Challenges if Sr. MW are Promoted without LHV Training

Respondents (n = 149)

Respondents (n = 58)

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To explore more about the qualitative information on the bottlenecks to become LHV, factors influencing on LHV profession and their future career prospects, 17 LHVs (1 representative each from 17 States and Regions), 10 junior midwives (less than 2 years of service), 10 senior midwives (more than 10 years of service) were invited to participate in a one-and-half-day workshop for focus group discussion and case scenario discussions in Dec 2018. To include voices from the communities, 9 community representatives were also participated in focus group discussion on the community perspective on primary health care received from midwives and LHV. Moreover, 15 Key informant interviews were conducted with (3 Leadership Personnel from Department of HRH, 3 Leadership Personnel from Department of Medical Service, 3 Leadership Personnel from Department of Public Health, 2 Leadership Personnel from Lady Health Visitor School, 2 Leadership Personnel from Myanmar Nurse and Midwife Council and 2 Leadership Personnel from Myanmar Nurse and Midwife Association). The findings were analyzed and summarized as per following thematic areas:

Career Ladder and Continuing Personal and Professional Development

Bottlenecks to become LHV

Each year, only limited number of LHV training is accepted (Eg. 8 out of 100 applicants per State/Region; Or approximate 10 from Regions and 3 from States for each year).

There is only one LHV training school and duration is 9-month.

To become LHV, MW receives service mark (1 for a year of service/ 3 for a year of service at remote areas). Therefore, long waiting time although the candidate met 3-year service criteria for entrance. It usually takes at least 8 years to get entrance. Feeling demotivated to apply for/to become LHV.

The service performance assessment is usually given by TMO with sealed envelope for LHV entrance. No transparency, inequity and bribery occurs.

LHV entrance exam selection is unclear (Don’t know reference books for exam)

Even after passing written entrance test, the candidates were asked if they have enough money/family matters and then their entrance was failed. It is very difficult to get LHV entrance. In someplace, specific selection criteria is not applied/ not systematic.

There is huge opportunity cost including leaving current posting, budget, family matter and transfer.

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Their main drives to become LHV is that they adore their profession and uniform very much and interested in public health.

Drives NOT to become LHV

MW have their own responsible villages while LHV don’t have.

The only difference between MW and LHV is management duty which is not need to attend 9-month training. Management skills already acquired after several years of services.

Career ladder for LHV is not clear

LHV career ladder is very difficult and unclear, so don’t want to try.

There is two possible career pathways for LHV: to become HA or THN. However, there is no career advancement of LHV as THN (since 2014).

HA training is 1-year in Magway, not-convenient, no more uniform. THN training is only 2-moth and more convenient and there is uniform.

No opportunity to be PHN (no route from LHV, and from nursing only)

Previously, service years as Midwives, service years as LHV and graduate are criteria to become THN. At present, BNSc graduate can get THN post. Therefore, LHV’s career advancement opportunity has been lost/blocked.

There should be a career pathway from THN to AD(MW ->LHV -> THN -> NO -> AD)

Concerns about BMSc program

Want to attend BMSc separate training for in-service MW/LHV (a separate training/class with newly matriculated youngsters)

To attend BMSc 2 year program will be very challenging (duration of the course, vacancy rate during 2-year training)

It will be great if duration of BMSc program can be reduced for LHVs who have years of service/ MW with certain number of years.

Criteria for BMSc entrance

Will Certificate MW/LHV will have equal opportunity as Diploma?

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Age limitation? (At present, LHV entrance is under 45 years and THN is 55 years)

What will be career ladder/opportunity for LHV after finishing BMSc course?

Concerns about future of LHV

Does the MoHS have plan to keep production of LHV?

If the MoHS decided no more production, what would be the roles of current LHVs?

Recommend to continue production of LHV with shorter duration of LHV training and promotion/career ladder.

Continuing Personal and Professional Development (CPPD)

Receive BEmONC training and more CPPD opportunities will be need when CPD points becomes essential for renewal of license. (Note: challenges in renewing license in time for those who serve in far remote areas).

CPPD is important, but no time for this because the MW/LHV are very busy with responsibilities (described and un-described).

Some of the participant read during their free time and attend computer training for their CPPD.

Some of the participants were not aware of CPPD.

Midwives and LHVs’ Scopes of Work

Responsibilities and Competencies

Perform MCH services, public health, disease control, medical care

Coordination with other BHS (SH, Environment, Mobile Clinic, Disaster Management, Data collection, Inspection of Restaurant,

Feeling confident on MCH and EPI, less confident on disease control.

Data recording skills need to be strengthened.

Performance depend also on training exposure, supervisor, own attitude, continuing education

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Roles and Responsibilities

Although JD are defined on paper, there is still unclear in reality.

At least 2-3 hour per day is used for data recording

At least 2-day is needed each month for monthly report. Data recording is hidden task/burden for midwives.

Role Conflicts

Role Conflict between Midwives and PHS II is a huge problem.

PHS II have quality issues with limited knowledge and skills set.

LHVs can contribute health services better then PHS1

Supports and Supervision

Except from LHVs, there is low support from supervisors (HA, THO).

HA are different cadres, could not provide on-job training for clinical skills

Safety and Protection

Security and safety is not guarantee.

Need specific policy and regulation for injection treatment (law protection)

Suggestions

Clear JD and responsibilities (would like to perform main duty well).

If possible, more production and deployment of midwives instead of PHS II.

Capacity building from government as well as from NGOs. Monthly CME activities and evaluation of trainings/competencies

Community Perspectives on Midwives and LHV scopes of work

Previously, quite reluctant to seek medical care due to financial and communication gaps. It has been improved a lot in the past few years. Better communication and some FOC treatment are pulling factors for seeking medical care.

Some of the community prefer MW from the other places because there is tendency to stay most of the time at the sub-center and community are more accessible to health services.

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At Sub-center, PHS II seems to be just an assistant/a companion to MW because they have limited skills and knowledge

Midwives usually implement activities. LHVs supervise and included in the team for major activities (projects, mass immunization, disaster/emergency)

Difference between roles and responsibilities of MW and LHV

Responsibilities MW LHV

RMNCH, Nutrition, CD/NCD, Immunization, Medical services

Main Responsibilities Supervision and Supporting of MW’s services provision

Supervision MW supervise and coach to AMW, harder than LHVs supervising MWs because AMW are volunteers and not systematically trained

On-the job training to (newly posted) midwives

Reporting MW reports to LHV, promoted midwife, who knows the job nature, sympathize, understand the issues, helps solving the problems (since LHV are mid-level managers, they might have limited decision making power)

LHV reports to HA, who mostly are not the same cadre of LHV. Limited knowledge in job nature and understanding of issue (since HA are head of RHC, they have more power of decision making)

Replacement responsibilities

Take the responsibilities of MW/HA If those cadres take leave/ transfer/attend training (Over-workload/ Burden of workload)

Develop and Submit Reports

Need to develop report for self’s sub-center

Need to combine and check data validity of all sub-centers MW reports under RHC

Coordination More coordination responsibilities and solving communication challenges of midwives

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Additional Tasks Management, Microplanning Administration and Supervision

Training opportunities

More training for MW Limited numbers of training for LHV Limited IEC received

Career Development Options for MW and LHV

No. How do we do this? Resources Required Potential Risks and Mitigation

1 Condense LHV course for MW

Shorten the duration

Focus on management and vital statistics

Increase intake #

Increase training sites

Quality of training

Quality of graduate

2 Short courses for promotion as Sr.MW

Obtain experiences from on-the-job

Short course on-the-job training on vital statistics and management skills

Selected courses

Training sites

Training type

Difficult to accept the changes

Difficult to accept their leadership by Jr.MW

Quality in data management

3 Condense B.M.Sc course for LHV Revise entry criteria

Selected courses

B.M.Sc can not replace LHV and MW who work primarily at rural area

4 Open THN/THM position for LHV

No THN post offer for LHV since 2014

-Policy and Career criteria favorable as required for Nr to THN

Roles and responsibilities of THM need to be clearly described to avoid conflict

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between THN and THM

5 Condense HA courses for LHV Service duration Attend training

Training duration

Most of the LHV do not interest in HA post

LHV doesn’t like HA as their supervisor because HA doesn’t have clinical background (THM and LHV are relevant to supervise MW as they have the same clinical background with management skills)

6 Post MW at hospital How – rotation between hospital and community?

Who – only Jr or all

Inter-professional conflict of respect

Midwives raised a concern of being treated inferiorly by nurses

After the thematic analysis of focus group discussion, the study team explored possible strategy options for LHV and MW future career prospects with the following 3 case scenarios: Case scenerio 1: Increase LHV production to fill current LHV gaps Case scenario 2: Develop Alternative Strategies to fill current LHV gaps and Case scenario 3: Stop production of LHV and develop the new channel as career ladder.

The participants discussed on these possible options by exploring possible strategies, how do we implement those strategies, identifying resources required and potential risks and mitigation, benefits and risks for adopting these strategies.

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Case scenario 1: Increase LHV production to fill current LHV gaps

Benefits of increase production

Enable to rapidly fill the gaps and resolve service coverage due to LHV gaps

Since the training time is shorter, the vacant period of her post in assigned area is shorter and the relieving time also is shorter

Could provide on-the-job training and close mentoring to new in-service midwives and hence build their confident in workplace

Support to attain SDG and UHC due to increase service coverage and quality of service delivery

Career development opportunity for MW as LHV

Reduce attrition as staff are motivated and more chance to become LHV

Since they are paid fully during training, shorter course will make the country use more workforce.

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Risks of mass production

1. Shortage of midwives due to increase attending LHV course and promoting to LHV

2. Proper planning and resources management (infrastructure, faculty, financial) for increase production

3. Sustainable plan for new LHV school if new LHV schools are opened to meet increase production

Case scenario 2: Develop Alternative Strategies to fill current LHV gaps

Benefits of adopting alternative strategies

1. Fill the LHV gap

2. No financial cost and time wasting

3. Allow more MW to have promotion opportunity

4. Allow midwives cadre to envision and hope for future

5. The graduated MW will join government service instead of working at INGO

6. Result in human resource development

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7. Can work more efficiently with career development

8. Enjoy in workplace

9. Fill the gaps of MW if there is vacant

10. LHV understand the life of MW because LHV are developed from MW

Risks of adopting alternative strategies

1. Unqualified midwives will face difficulty if promoted to Sr. Midwives

2. There will be difficulty for some midwives to accept the changes and the leaderships of Sr. MW

3. Will have affect on data management quality

Case scenario 3: Stop production of LHV and develop the new channel as career ladder

Benefits of continue production of LHV

1. Only LHV understand life of MW because LHV are developed from MW

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2. LHV have clinical and management skills therefore can take reliving for MW as well as HA when required

3. LHV is the front line health care provider being trusted, respected and depended by 70% of population in Myanmar

Risks of stop production of LHV and Risks of producing only BMSc midwives

1. Loss of MW career opportunity as LHV

2. Delay in public health intervention and hence effect to achieve the goals if LHV cadres is obsolete

3. Role conflicts between BMSc midwives and LHV

4. BMSc midwives will not have service experience and may encounter management issues (eg. the same scenarios as condense HA and BComHA)

5. Career prospects of BMSc is not clear yet

Summary and Recommendation

To fill the current 40% LHV sanction gaps, a number of innovative strategies and approaches are

discussed during the scoping analysis. Based on the potential risks and benefit, the following

strategy options are recommended for policy level discussion and decision making:

1). Option 1: Increase LHV production to fill the current gaps

Strategy 1: Increase number of LHV training school

Benefits: Rapidly fill the LHV gaps, career development opportunity for MW as

LHV, reduce attrition as staff are motivated and more chances to become LHV

Risks: Not enough infrastructure for new schools, faculty number, quality of

training, financial risks and sustainability of new LHV schools; Shortage of

midwives due to increase attending LHV course and promoting to LHV

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Strategy 2: Increase number of LHV trainee intake

Benefits: Rapidly fill the LHV gaps, career development opportunity for MW as

LHV, reduce attrition as staff are motivated and more chances to become LHV

Risks: Not enough infrastructure at current school, faculty number, quality of

training and financial risks; Shortage of midwives due to increase attending LHV

course and promoting to LHV

Strategy 3: Reduce course duration (condensed LHV course) and accept 2-3 LHV

batches per year

Benefits: Rapidly fill the LHV gaps, career development opportunity for MW as LHV, reduce attrition as staff are motivated and more chances to become LHV, as the training time is shorter, the vacant period of her post in assigned area is shorter

Risks: Need to develop condense LHV course to ensure quality of training, Faculty

number, financial risks, sustainability of new LHV schools

2). Option 2: Development alternative strategies to fill current LHV gaps

Strategy 4: Promote as Senior Midwife

Benefits: After serving certain number of years (eg. 5yr/8yr/10yr), midwives are

promoted as senior midwives. This will fill the LHV gap, no financial burden, more

promotion opportunity for midwives

Risks: Quality of management skills and data analysis for senior midwives if they

don’t have proper training, unqualified midwives will face difficulty if promoted,

possible role conflicts among Senior midwife and LHV

3). Option 3: Stop production of LHV and develop the new channel as career ladder

Strategy 5: Stop production of LHV and develop the new career ladder as BMSc

Midwives

Benefits: Creating a new channel BMSc midwives is upgrading education status

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Risks: Uncertain future for current LHVs and it will demotivate current LHVs

served in the public sector, Loss of MW career opportunity as LHV, role

conflicts/career ladder conflicts between BMSc midwives and LHV, career

prospects of BMSc is not clear yet.

In regards to future career prospects, Lady Health Visitor (LHV)’s career ladder as Township

Health Nurse (THN) or Township Health Midwife (THM) is highly recommended in addition to

Health Assistant option. More career opportunity for Midwives as LHV or senior midwives will

not only fill the required LHV gaps but also create more vacant posts for midwives for those who

has been promoted. Then, it will motivate the midwives to retain in the private sector and it can

further shorten delay waiting time for deployment of recently graduated midwives.

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Annex 1: Reference

1. National Health Plan (2017-2021), Ministry of Health and Sports, Myanmar. Online. Accessed on 12 December 2018. Available at http://www.mohs.gov.mm/search?question=national+health+plan

2. The Global Strategy for Health Resources for Health: Health Workfoce 2030. Online. Accessed on 10 Jan 2019. Available at http://www.who.int/hrh/resources/globstrathrh-2030/en/

3. Ministry of Immigration and Population, Department of Population, The 2014 Myanmar

Population and Housing Census: The Union Report, Census Report, Nay Pyi Taw, 2015.

4. Capacity utilization and strengthening career ladder of Basic Health Staff in Myanmar

( as of October, 2018), power point presentation by Dr. Than Lwin Htun, Health Promotion

Unit, Department of Public Health

Annex 2: Workshop Agenda (FGD and Groupwork):

Day 1 20 Dec 2018 Remark Time Topic

9:00-9:15 am Introductions and Ice-breaking All 9:15-9:45 am Presentation: A Road to Universal Health Coverage Jhpiego

9:45-10:15 am Tea Break

10:15-11:15 am

FGD 1 and 2: Roles and Responsibilities of LHV LHV FGD 3 and 4: Roles and Responsibilities of MW Sr & Jr MW FGD 5: Community Perspectives on Primary Health Care Community

11:15-12:00 noon Discussion (Group/Panel): Difference between scopes of LHV and MW

All

12:00 – 13:00 pm Lunch Break

13:00 – 14:00 pm FGD 1 and 2– LHV: Perspectives on Career Ladder and CPPD

LHV

FGD 3 and 4 – Sr.MW: Perspectives on Career Ladder and CPPD

Sr.MW

FGD 5 – Jr.MW: Perspectives on Career Ladder and CPPD Jr. MW

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14:00 – 14:15 pm Presentation: Current Shortage of BHS Jhpiego

14:15 – 15: 00 pm

Group Work: Case Scenarios 1: Risks and Benefits Group 1, 2 Group Work: Case Scenarios 2: Risks and Benefits Group 3, 4 Group Work: Case Scenarios 3: Risks and Benefits Group 5, 6

15: 00 – 15:30 pm Tea Break 15: 30 – 16:00 pm Presentations and Discussion All

Day 2 21 Dec 2018 Remark Time Topic

9:00-9:15 am Preliminary findings from FGDs Jhpiego 9:15-9:45 am Discussion All

9:45-10:15 am Tea Break

10:15-11:15 am

Group Work: Case Scenarios 1: Resources, Mitigation and Responsible persons

Group 1, 2

Group Work: Case Scenarios 2: Resources, Mitigation and Responsible persons

Group 3, 4

Group Work: Case Scenarios 3: Resources, Mitigation and Responsible persons

Group 5, 6

11:15-12:00 noon Presentation and Discussion All 12:00 – 13:00 pm Lunch and closing