Human resources for maternal and newborn health in Benin, Malawi, Tanzania and Uganda: a policy process-tracing analysis

Human resources for maternal and newborn health in Benin, Malawi, Tanzania and Uganda: a policy process-tracing analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Human resources for maternal and newborn health in Benin, Malawi, Tanzania and Uganda: a policy process-tracing analysis Ann-Beth Moller, Joanne Welsh, Max Petzold, Amani Siyam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7337394/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Central to the achievement of the Agenda for Sustainable Development and universal health coverage is an adequate, equitably distributed and fully supported health workforce. An adequate supply of health workers who possess the needed competencies and professional attitudes can deliver evidence-based, high-quality care across all levels of the health system, thereby contributing to better health outcomes. Methods This study analysed how the elements of the availability, accessibility, acceptability and quality framework have been integrated and used in human resource for health (HRH) policies and strategies related to the midwifery health workforce since 2010 in Benin, Malawi, Tanzania and Uganda. We applied the READ framework for our HRH policy and strategy policy tracing analysis. The stages of READ framework are: i) Ready your materials, ii) Extract data, iii) Analyse data and iv) Distil your findings Results Twenty HRH policies and strategies were included in the analysis. We found that all policies and strategies addressed aspects linked to availability and accessibility as well as the need for HRH quality improvements whereas acceptability was poorly represented. None of the policies and strategies mentioned the Sustainable Development Goals (SDG) target 3.c “substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States” and indicator 3.c.1 “health workforce density and distribution. Indicating a profound disconnect between reflecting the impact of national HRH interventions against the global accountability to the SDGs policy development framework. Conclusion Efforts and investments are needed to tackle the gaps and inequalities in the availability, accessibility, acceptability and quality of the midwifery workforce. Newer modalities of investments in their quality of pre-service training, remain imperative to accelerate the transition towards universal access to quality and more acceptable and accessible maternal and newborn health care services and consequently improved health outcomes. Human resources for health health policies health workforce policy tracing sub-Saharan Africa Background Many countries are facing a human resources for health (HRH) crisis, lacking a competent health workforce (HWF) required to deliver universal health coverage (UHC) matching population needs [ 1 ], including care for women and newborns, as targeted by the Sustainable Development Goals (SDG) and the UHC agenda [ 2 , 3 ]. The importance of the HWF in achieving SDG goal 3 “ensure healthy lives and promote well-being for all at all ages” is reflected in SDG target 3.c “substantially increase health financing and the recruitment, development, training and retention of the HWF in developing countries, especially in least developed countries and small island developing States” and indicator 3.c.1 “health workforce density and distribution”. [ 2 ] Sub-Saharan Africa (SSA) has the lowest HWF density globally with 2.5 medical doctors, and 16.4 nursing and midwifery personnel per 10 000 population in 2022, significantly below the global level of 18.7 medical doctors, and 39.4 nursing and midwifery personnel per 10 000 population. [ 4 ] Globally, projections suggest that by 2030 the HWF shortage will amount to approximately ten million. SSA will account for 52% of the projected global HWF shortage, missing 5.3 million health workers by 2030. [ 1 ] HWF shortage is often linked to lack of investment in education, an absence of HRH policies, international migration of health workers and a weak information system monitoring the stock of the labour market dynamics to inform policies and programmes. [ 5 ] The COVID-19 pandemic exacerbated health worker shortages and highlighted the fragility of the health care system. Those working during the pandemic were faced with risk of infection, exhaustion, stress, and anxiety which led to compromised physical and mental health for numerous health workers, and some leaving their profession. [ 6 – 9 ] Recent cuts in official development assistance (ODA) continue to affect layoffs, hiring freezes, and unpaid roles, particularly affecting frontline workers including nurses, midwives, and community health workers, and scaling back or shutting down of programmes that provided ongoing training and professional development, stalling opportunities for career growth and reducing workforce quality. [ 10 ] In addition to HRH shortages, evidence suggests that prior to entering the HWF, pre-service training in SSA does not always meet international standards. [ 11 ] The knock-on effect is reduced competence levels [ 11 , 12 ] which, in turn, affects quality of care delivered. Furthermore, inadequate remuneration packages and lack of an enabling working environment can leave health care workers demotivated and unprepared to deliver care required. [ 13 – 15 ] Collectively, these factors influence health outcomes for the population. Maternal and newborn health (MNH) is one example. Under SDG 3 and the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) there are specific targets related to MNH.[ 2 , 16 ] These include ensuring women have access to family planning, antenatal care, and increasing the number of births attended by a skilled health personnel. [ 17 , 18 ] As a result, essential services such as antenatal, intrapartum, and postnatal care have become more accessible with evidence suggesting increased coverage for all these services in SSA. [ 19 ] Access to skilled health personnel during childbirth, an indicator in the SDG framework (SDG indicator 3.1.2), increased globally from 80 to 87% between 2015 and 2024 with SSA experiencing the lowest coverage (73%) in 2024.[ 4 ] Despite this, high levels of maternal and newborn morbidity and mortality persist. [ 4 ] The World Health Organization (WHO) positioned a well-performing and competent HWF as one of the six building blocks for health system strengthening. [ 20 ] To ensure the well-being of women and newborns, as well as positive health outcomes for both groups, women and newborns need access to a health system which provides timely evidence-based quality care, delivered by educated and competent midwifery care providers. However, numerous countries, including many in SSA, struggle to ensure the four essential dimensions of effective coverage applied specifically to the midwifery care health workforce namely: availability, accessibility, acceptability and quality, also referred to as the AAAQ Framework. [ 21 ] Box 1. provides the operational definition of the AAAQ framework dimensions. Box 1. Availability, accessibility, acceptability and quality (AAAQ) framework [ 21 ] Framework dimensions Operational definition Availability The sufficient supply, appropriate stock of health workers, with the relevant competencies and skill mix that corresponds to the health needs of the population. Accessibility The equitable distribution of health workers in terms of travel time and transport (spatial), opening hours and corresponding workforce attendance (temporal), the infrastructure’s attributes (physical—such as disabled-friendly buildings), referral mechanisms (organizational) and the direct and indirect cost of services, both formal and informal (financial). Acceptability The characteristics and ability of the workforce to treat all patients with dignity, create trust and enable or promote demand for services; this may take different forms such as a same-sex provider or a provider who understands and speaks one’s language and whose behaviour is respectful according to age, religion, social, cultural values, etc. Quality The competencies, skills, knowledge, and behaviour of the health worker as assessed according to professional norms (or other guiding standards) and as perceived by users. Persistent gaps across these dimensions have contributed to stagnating MNH outcomes, particularly in SSA[ 22 – 26 ], and threaten progress toward global targets outlined in strategies such as Every Woman Every Newborn Everywhere [ 27 ] (previously Every Newborn Action Plan[ 17 ] and Ending Preventable Maternal Mortality [ 18 ]), the Global Strategy for Women’s, Children’s and Adolescents Health 2016–2030[ 16 ] and targets included in the SDG agenda [ 2 ]. To ensure continued improvement in MNH outcomes it is important to understand how national HRH, and other national policies and strategies have evolved. The aim of this study was to examine how the elements of the AAAQ framework have been integrated and used in HRH policies and strategies related to midwifery health workforce since 2010 in four countries in SSA. The case study countries are Benin, Malawi, Tanzania and Uganda. These countries were selected to complement earlier research related to midwifery care providers’ competencies after pre-service training and intrapartum competencies conducted in the same countries. [ 11 , 28 ] The findings from both studies underscore critical deficiencies in midwifery health workforce knowledge and practical skills, highlighting the urgent need for comprehensive curriculum reform, as none of the reviewed training programs fully aligned with global standards. These gaps point to the necessity of sustained investment in continuing professional development and the implementation of system-level interventions to create an enabling environment for ensuring quality MNH care is accessible and available. In addition, these countries are on the WHO’s “health workforce support and safeguards list, 2023. [ 29 ] Country inclusion in the list is based on a national density of doctors, nurses and midwives below the global median of 49 per 10 000 population and an universal health service coverage index below 55 (out of 100). [ 30 ] Table 1 provides an overview of selected MNH outcomes and Table 2 provides the latest available densities of medical doctors, nursing and midwifery personnel per 10 000 population for the case study countries. [ 31 ] Table 1 Selected MNH outcomes in Benin, Malawi, Tanzania and Uganda (latest available data) Indicator Benin Malawi Tanzania Uganda Intrapartum care % of births in a health facility (15–49 years) [ 32 ] 85.1 91.4 81.2 73.4 % of births attended by skilled health personnel (15–49 years) [ 32 ] 83.9 89.8 84.8 74.2 Maternal and perinatal mortality Maternal mortality ratio per 100 000 live births (2023) [ 23 ] 518 (UI a : 393–740) 225 (UI: 153–352) 276 (UI: 192–429) 170 (CI:116–298) Neonatal mortality rate per 1 000 live birth (2023) [ 22 ] 28 (CI b : 21–38) 19 (CI:11–33) 21 (CI:16–27) 18 (CI:11–28) Stillbirth rate per 1 000 total births (2023) [ 26 ] 19 (CI b : 16–22) 16 (CI: 12–20) 19 (CI: 14–26) 15 (CI: 12–17) Perinatal health outcomes % low birthweight of all live births (< 2500 g) (2020) [ 25 ] 16.4 (CrI c : 14.8–18.2) 15.6 (Crl: 14.2–17.1) 9.7 (Crl: 8.4–11.2) Data not published d Preterm birth (rate per 100 live births (< 37 weeks of gestation) (2020) [ 24 ] 6.9 (CrI c : 3.6–12.9) 14.5 (CrI: 9.5–21.6) 8.4 (CrI: 4.3–15.6) 10.0 (CrI: 6.1–16.0) a . 80% CI: 80% confidence interval. b . 90% CI: 90% confidence interval. c . 95% CrI: 95% Bayesian credible interval. d . For countries with no data input the low birthweight estimates are not published which was the case for Uganda. Table 2 Density of medical doctors, nursing and midwifery personnel in Benin, Malawi, Tanzania and Uganda (latest available data )[ 31 ] Benin Malawi Tanzania Uganda Occupation Density per 10 000 population Medical doctors 2.2 (2023) 0.5 (2022) 1.3 (2022) 1.9 (2022) Nursing personnel 4.4 (2023) 4.8 (2022) 6.9 (2023) 15.7 (2022) Midwifery personnel 1.7 (2023) 0.3 (2022) Not reported after 2006 a 7.0 (2022) a . Nurses and midwives are currently dual trained In Tanzania and reported under nursing personnel. Methods Study design and setting Various contextual factors, HRH policies and strategies and MNH health outcomes are present in Benin, Malawi, Tanzania and Uganda, and therefore an exploratory case-study policy process tracing approach was applied. Policy process tracing is a method that attempts to identify the underlying processes in order to explain outcomes “what mechanismic explanation accounts for the outcome?”. [ 33 ] The approach aims to determine whether an independent variable(s) really affects the dependent variable(s) and to what effect. The independent variables in the study are HRH policies and strategies regarded as causes of the change in the dependent variables which are health workforce availability, accessibility, acceptability and quality. We used the READ framework for our policy process-tracing and strategy document analysis. As a systematic approach, READ provides a framework for identifying appropriate documents and gleaning relevant information from them. The stages of READ framework are: i) Ready your materials, ii) Extract data, iii) Analyse data and iv) Distil your findings. Each stage will be discussed as we outline data collection and data analysis method. [ 34 ] Data compilation and management Under the READ framework we “Readied our materials”. This required us to set parameters in terms of the nature and volume of documents we wished to identify and analyse. This was achieved by defining the following criteria: Topic: HRH policies and strategies related to maternal and newborn health. Dates of inclusion: We opted to include documents published from 2010 to the most recent identified which was published in 2021 to explore the policy environment as prior limited national and global attention had focused on the HWF. Places to search for relevant documents available in the public domain: To obtain HRH policies and strategies we searched three different sources considered most pertinent: i) the Ministry of Health website for the four countries, ii) WHO Global Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health (SRMNCAH) Policy Database ( https://platform.who.int/data/maternal-newborn-child-adolescent-ageing/national-policies ), and III) African Index Medicus ( https://www.globalindexmedicus.net/biblioteca/aim/ ). The SRMNCAH Policy Database, a policy document repository, which contains document shared by WHO Member States including national policies, strategies, laws, guidelines, and reports that are relevant to the areas of SRMNCAH obtained during rounds of the Global SRMNCAH Policy Survey. The African Index Medicus is an international database for African health literature implemented by WHO and African partners. The key words used were human resources for health, health policies, health system, strategic plan and the country names. All sources were accessed between 6 to 8 July 2025. Once relevant documents were identified using the above criteria, we moved onto the second stage of the READ framework to “Extract data”. This was achieved by using an Excel spreadsheet with each column representing a category of information we wished to extract and pertinent to the AAAQ framework. Documents were closely read by two reviewers (ABM and JW) with required information extracted and added to the spreadsheet (ABM and JW) (Additional file 1_data extraction_policies). Data analysis Once all relevant policy documents had been retrieved and pertinent information extracted and added to the Excel spreadsheet, we followed step three of the READ framework, “Analyse data”, an iterative process of data synthesis by reviewing the content of the documents closely and considering their purpose. Following step four of the READ framework, we then “distilled our findings”. This was achieved by mapping the relevant information from the policies and strategies to the AAAQ framework using the operational definitions to synthesise the data. Main categories were developed where possible for each aspect of the AAAQ framework. The documents were divided into two groups: i) specific HRH policy and strategic plans (overarching HRH policy/strategy) and ii) other policies and strategic plans considering HRH aligned to a broader health policy or health sector strategic plan. This was done as a very limited number of specific HRH policies and strategies are available for these countries and we wanted to explore how HRH was embedded in other policy and strategy documents which could provide critical information. Results Twenty HRH policies and strategies are included in the analysis covering the period from 2010 to the most recent identified which was published in 2021. Three policies were identified from Benin, all of which fell in the category ii “other policies and strategic plans considering HRH” as no specific HRH policy and strategy was located. From Malawi, five policies were included, one specific HRH strategy (draft) and four other policies and strategic plans. According to the literature it is documented that Malawi has an HRH Strategic Plan, 2018 to 2022 [ 35 , 36 ] however, currently it is not available in the public domain. Two HRH strategies are included from Tanzania and three other policies and strategic plans. From Uganda one HRH strategy and six other policies and strategic plans were located. Additional file 2 shows the PRISMA flow diagram charting this process. Benin is the only country which does not have an overarching HRH policy and strategy, whereas Malawi and Tanzania have developed two HRH policies/strategies. Uganda recently (2021) published a new strategy covering the period from 2020 to 2030 which is a follow on to the 15-year HRH Strategic Plan 2005 to 2020 which ended in June 2020. A detailed operational plan with targets and cost is only included in the Uganda HRH strategy 2020 to 2030 with 5-year rollout operational plan for 2020/21 to 2024/25. The HRH strategies from Malawi and Tanzania included strategic objectives and implementation framework but no concrete plan on how to achieve the objectives. In addition to the overarching HRH policy and strategy each country has included aspects related to HRH in their health policy and/or health sector strategic plans. All the documents have specific reference to maternal newborn and/or infant mortality and describe concerns about continuous high levels of maternal and newborn mortality that continue to fall behind national and global targets [ 2 ]. Adverse outcomes such as preterm birth, low birthweight and stillbirth are not mentioned or considered in any of the documents. In terms of the AAAQ framework, all HRH specific policies addressed availability of the HWF. All HRH policies (Malawi, Tanzania and Uganda) identified a need to focus on monitoring and planning for HRH, with all referring to retention of staff as a method to increase availability. Tanzania and Uganda also commented on the need to strengthen recruitment, with Uganda also noting the importance of reducing absenteeism as mechanisms for improving availability of staff. Regarding accessibility, all HRH specific policies commented on the need for an equitable distribution of HRH staff. Acceptability was poorly represented in policies for HRH with only the Ugandan policy mentioning the need to improve acceptability but providing no further detail in terms of what this means or how to achieve it. All HRH specific policies referred to quality of HRH in terms of improving pre-service training, as well as improving continuous professional development. To achieve the former, the Tanzanian policies discussed improving training curricula, strengthening the capabilities of teaching faculty and improving accreditation for training institutions. The Ugandan document also discussed improving training curricula as well as the need to improve clinical training, standardize exams, performance and manage staff throughout their working life (Table 3 . AAAQ framework and human resources for health policies and strategic plans). Table 3 Availability, Accessibility, Acceptability and Quality (AAAQ) framework and human resources for health policies and strategic plans Country Title of policy/ strategic plan/year Availability Accessibility Acceptability Quality Specific reference to MNH Benin None identified Malawi Malawi Human Resources for Health Strategic Plan, 2018–2022. Not available in the public domain but have been referenced in the literature [ 35 , 36 ] Malawi Human Resources for Health Strategic Plan 2012–2016. Draft [ 37 ] Improve the capacity for HRH monitoring and planning. Improve HRH retention. Adequate and equitable distribution of HRH. Strengthen HRH training and continued professional development. Support capacity building agendas of health training institutions. Reduction in maternal and newborn mortality. Tanzania Human Resource for Health and Social Welfare Strategic Plan 2014–2019 [ 38 ] Improve the capacity for HRH monitoring and planning. Improve HRH retention. Strengthen recruitment. Equitable distribution of HRH. Strengthen HRH training and continued professional development (i.e. improve curricula for training programs and improve accreditation of training institutions). Reduction in maternal and under five mortality. Tanzania National Human Resources for Health Strategy 2020–2025 [ 39 ] Improve the capacity for HRH monitoring and planning. Improve HRH retention. Strengthen recruitment. Equitable distribution of HRH. HRH recruitment in low density areas. Strengthen HRH training and continued professional development (i.e. improve curricula for training programmes, competence-based curriculum and faculty). Reduction in maternal and newborn mortality. Uganda The Human Resources for Health Strategic Plan 2020–2030 [ 40 ] Improve the capacity for HRH monitoring and planning. Improve HRH retention. Strengthen recruitment. Reduce absenteeism. Adequate and equitable distribution of HRH. Improving acceptability of workforce is mentioned, but no plans or examples of how to do this are given. Strengthen HRH training and continued professional development (i.e. improve curricula for training programmes, improved clinical training, standardized examination). Maintain regular performance reviews and appraisals based on performance plans and contracts. Strengthen professional associations as a mechanism for HWF empowerment. Reduction in maternal and newborn mortality. For policies and strategies not specific to HRH, all documents from Benin, Malawi and Tanzania, and four out of the six documents from Uganda addressed availability. To improve availability, a variety of strategies were suggested including strengthening HRH planning (Benin, Malawi, Tanzania and Uganda), ensuring an appropriate supply of staff (Benin, Malawi, Tanzania and Uganda), focusing on recruitment (Benin, Malawi and Uganda) improving retention (Benin, Malawi, Tanzania and Uganda) and reducing absenteeism (Uganda). Regarding accessibility, all documents from Benin, Malawi, Tanzania and one of the six documents from Uganda mentioned improving HRH accessibility. This was discussed in terms of equitable distribution of HRH (Benin, Malawi, Tanzania and Uganda), provide health facilities with appropriate equipment (Benin), appropriate referral systems (Malawi, Tanzania and Uganda), improved access to emergency transport (Malawi), and addressing financial barriers in accessing care (Malawi and Tanzania). As with the HRH specific policies, the concept of HRH acceptability was poorly represented in other policies and strategies with no mention of the concept in the Benin policies and strategies, and only one of the four documents from Malawi addressing it. Tanzania and Uganda mentioned acceptability more consistently with all Tanzanian documents and four of the six Ugandan documents identifying the need to improve HRH acceptability. Strategies suggested for achieving this included client-centredness and being considerate of people’s personal circumstances, meeting the expectations of the population, addressing community needs, people-centred respectful care with a human rights-based approach, improving professional standards and accountability towards clients, and client charters. For each country, all documents made recommendations for improving HRH quality. Strategies included improving training (Benin, Malawi and Tanzania) and continuous professional development (Benin, Malawi and Tanzania), improving staff motivation (Benin and Malawi), accreditation of training institutions (Malawi and Uganda), performance management of staff (Tanzania and Uganda), strengthening regulatory bodies (Uganda), and ensuring staff have access to and follow guidelines and protocols (Uganda). Details provided in Additional file 3_Other policies and strategic plans considering HRH. Surprisingly, the process-tracing analysis revealed that none of the policies and strategies mentioned the SDG target 3.c and indicator 3.c.1. related to the HWF. [ 2 ] This signals a profound disconnect between reflecting the impact of national HRH interventions against the global accountability to the SDGs policy development framework. Discussion Findings from the review of strategies and policies revealed potential approaches to improve the availability of the midwifery workforce including recruitment, retention and tackling absenteeism. Recruitment of health care staff would appear to be an obvious solution to HWF shortages however, reasons exist as to why this may not be possible. The level of employment in a country’s health sector is in large part determined by health labour market dynamics, not the population health needs or the health worker education capacity alone. [ 41 ] National government budgets for healthcare may not align with health care service demands, leading to an inability to recruit the required HWF. Commentary from Malawi suggests this is a real issue. Muula (2023) posits that Malawi produces hundreds of health care professional graduates annually, who if employed would resolve HRH shortages. [ 42 ] Evidence suggests that improving retention of the current HWF is complex. Retention is associated with working conditions, availability of equipment and resources, ability to provide quality care, salary, opportunities for career progression, housing availability and quality (where housing is provided) as well as the feeling of being valued by colleagues. [ 43 – 45 ] Addressing these issues is multifaceted and requires significant investment from national government. Reducing absenteeism to improve HRH availability was proposed in four of Uganda’s policies and strategies. However, absenteeism was not mentioned in any policy documents from Benin, Malawi, and Tanzania. Whilst acknowledging the complexity of HRH absenteeism, Ackers et al. [ 44 , 46 ], go as far as saying that failure of doctors to present for work is one of the causes of maternal mortality in Uganda. Research by Zhang et al. (2021) in Uganda found a 15% absenteeism prevalence on monitored days, but this rate was higher, 42% in lower-level health clinics. [ 47 ] Such absenteeism not only affects the availability of the HWF, but also the accessibility and acceptability of HRH, with absenteeism associated with lower rates of health care utilization at lower-level facilities. Whilst studies call for a crackdown on absenteeism[ 44 , 47 ], Di Giorgio et al. (2020)[ 48 ] and Ashley Sheffel et al. (2024)[ 49 ] highlight that reducing absenteeism without addressing gaps in health care worker competence would only modestly increase the average care readiness that meets minimum quality standards and the health system will continue to be ineffective. Tackling HWF absenteeism requires a greater understanding of its causes, which may include working conditions and remuneration. Addressing these factors and their interconnected effects may improve availability of the HRH workforce in SSA. Our review of the strategies and policies highlighted recommendations for an equitable distribution of the health workers between rural and urban areas, as well as reductions in out-of-pocket expenditure for patients as a means of improving patient accessibility to the HWF. The unequal distribution of health care facilities and resources, including the HWF, is not a new phenomenon with these disparities widely reported in the literature.[ 1 , 50 ] Similarly, suggestions for tackling these issues are not new, and have been consistently recommended in various reports and strategies for several years. [ 51 – 55 ] Realizing the ambition of an accessible HWF will require significant financial commitment from government to ensure health clinics and hospitals that are equipped with adequate and competent health workers and resources are made readily available in the most needed areas. Notably, few strategies referred to improving the acceptability of HRH. This is somewhat surprising, as the literature pertaining to the importance of respectful maternity care is abundant. [ 56 – 58 ] Research from all four study countries indicates respectful care in the maternity setting is lacking. [ 59 – 63 ] Tackling disrespect and abuse in the health care setting, particularly the maternity setting, is an essential component of improving acceptability of the HWF. Improving the quality of the HWF competence is imperative for better and desirable health outcomes and if quality of care is to be enhanced. The documents reviewed in this study heavily focused on the need to improve the quality of pre-service training for health care professionals as well as continuous education as a means of improving the quality of the HWF. These recommendations are valid given current evidence which suggests deficiencies in pre-service and in-service training of health care professionals contributes to a lack of a skilled HWF. [ 11 , 49 , 64 – 66 ] Many of the reviewed HRH policy documents across countries were found to be repetitive, often reiterating the same challenges and proposed solutions without demonstrating clear evolution or refinement of interventions over time. For example, in Benin, the issue of “equitable distribution of HRH” within the accessibility dimension was consistently highlighted in all three national documents published between 2009 and 2018. Similarly, in Malawi, the recommendation to “improve HRH retention” under the availability dimension appeared in four separate policy documents issued between 2011 and 2022 (please refer to details in Additional file 3). Despite the repeated emphasis on these critical issues, the strategies often lacked specificity and actionable guidance on how to achieve meaningful impact. This pattern suggests a gap between policy formulation, planning and implementation, underscoring the need for evidence-informed, and results-oriented HRH strategies that offer a mix of policy solutions. It is important to acknowledge that changes in the HWF are not solely attributable to national strategic plans and policies. A range of contextual factors influence the implementation and effectiveness of these strategies, including the prevailing economic conditions, political commitment, public health emergencies such as pandemics, patterns of health worker migration, and broader HRH management practices. These factors vary significantly across settings and over time. Additionally, several of the strategies and policies reviewed in this analysis were only recently published and may not yet have been fully implemented, limiting the ability to assess their impact on workforce outcomes. Gaps in midwifery care providers competencies, shortages and imbalances are perhaps the most prominent bottleneck threatening the attainment of UHC and the health-related SDGs, as well as other national and global health priorities. Recognizing the HWF challenges the 78th World Health Assembly in May 2025 extend the “WHO’s Global Strategic Directions for Nursing and Midwifery 2021–2025” to 2030. The resolution emphasizes the urgent need for investment in HWF education, fair remuneration, safe working conditions, and equitable distribution—particularly in the context of global health emergencies, migration, and persistent workforce shortages. [ 67 ] Conclusion Tackling the factors that influence the availability, accessibility, acceptability, and quality of the midwifery health workforce in Benin, Malawi, Tanzania, and Uganda is a complex matter. Exacerbated by inadequate data impeding strategic workforce planning by obscuring the true supply, distribution, and competencies of health professionals. Without reliable information, governments and health institutions struggle to forecast future needs, leading to mismatches between training outputs and service demands. [ 49 ] Moreover, the lack of standardized data on workforce qualifications, licensure, and continuing professional development limits the ability to monitor and assure the quality of care. In the absence of such oversight, health systems may be unable to detect or address declines in clinical competence, with direct implications for patient safety and outcomes. [ 68 ] The global development landscape is facing a significant cut in ODA, with profound implications for low- and middle-income countries. According to the Organisation for Economic Co-operation and Development, net ODA is projected to decline by 9–17% in 2025, following a 9% drop in 2024. [ 69 ] Latest estimates of the United States Agency for International Development assistance cuts suggest that if withdrawals stand, this could include a potential 88% cut in support to maternal and child health aid, and 94% cuts to programming for family planning and reproductive health. For the countries in our study is it estimated that the cuts as percentage of country programme will be a 58% reduction in Benin, 64% in Malawi, 38% in Tanzania and 66% in Uganda. [ 70 ] Powerful commitments at the highest-level, sustainable investment and agility in policy-decisions from national governments must be emphasized, regularly monitored, and reassessed to influence the centrality of health workforce development in the context of the current funding situation govern effective HWF policies and MNH health care services. Newer modalities of investments in the midwifery health workforce, particularly in the quality of pre-service training, remain imperative to accelerate the transition towards universal access to quality and more acceptable and accessible MNH health care services and consequently improved MNH outcomes. Abbreviations AAAQ Availability, Accessibility, Acceptability and Quality MNH maternal and newborn health HRH human resources for health HWF health workforce ODA official development assistance READ Ready your materials, Extract data, A analyse data and Distil your findings SDG Sustainable Development Goals SRMNCAH sexual, reproductive, maternal, newborn, child and adolescent health SSA Sub-Saharan Africa UHC universal health coverage WHO World Health Organization Declarations Ethics approval and consent to participate All data used in the study are publicly available therefore ethical approval was not required. Consent for publication Not applicable. Availability of data and materials All original data are publicly available. Competing Interests The authors declare no competing interests. The authors received no funding for this work. Authors' contributions Conceptualization: AB M. Data curation: AB M and JW. Formal analysis: AB M and JW. Methodology: AB M and JW. Writing original draft: AB M. Writing – review and final editing: AB M, JW, AS and MP. Acknowledgments The authors would like to thank Mandip Aujla for her valuable review and insightful comments on earlier drafts of this manuscript. References Boniol M, Kunjumen T, Nair TS, Siyam A, Campbell J, Diallo K. The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage? BMJ Glob Health 2022, 7(6). Sustainable Development Goals. [ https://sustainabledevelopment.un.org/index.html] United Nations. Political Declaration of the High-level Meeting on Universal Health Coverage: expanding our ambition for health and well-being in a post-COVID world - PGA Text as of 1 September 2023. In. New York (N.Y.); 2023. Department of Economic and Social Affairs (DESA). The Sustainable Development Goals Report 2025. In. New York: United Nations; 2025. World Health Organization. Global strategy on human resources for health: workforce 2030. In. 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Health Policy Plan. 2021;35(10):1424–31. Nyoni J, Christmals CD, Asamani JA, Illou MMA, Okoroafor S, Nabyonga-Orem J, Ahmat A. The process of developing health workforce strategic plans in Africa: a document analysis. BMJ Glob Health 2022, 7(Suppl 1). Berman L, Prust ML, Maungena Mononga A, Boko P, Magombo M, Teshome M, Nkhoma L, Namaganda G, Msukwa D, Gunda A. Using modeling and scenario analysis to support evidence-based health workforce strategic planning in Malawi. Hum Resour Health. 2022;20(1):34. Ministry of Health. Malawi: Malawi human resources for health strategic plan, 2012–2016 (Draft). In. Lilongwe; 2018. Ministry of Health and Social Welfare United Republic of Tanzania. Human resource for health and social welfare strategic plan 2014–2019. In. Dar es Salaam, Tanzania; 2014. Ministry of Health United Republic of Tanzania. National Human Resources for Health Strategy 2020–2025 In. Dar es Salaam, Tanzania; 2020. Ministry of Health Uganda. The Human Resources for Health Strategic Plan 2020–2030. In. Kampala, Uganda; 2021. Sousa A, Scheffler RM, Koyi G, Ngah SN, Abu-Agla A, M'Kiambati HM, Nyoni J. Health labour market policies in support of universal health coverage: a comprehensive analysis in four African countries. Hum Resour Health. 2014;12:55. Muula AS. The paradox of Malawi's health workforce shortage: pragmatic and unpopular decisions are needed. Malawi Med J. 2023;35(1):1–2. Twineamatsiko A, Mugenyi N, Kuteesa YN, Livingstone ED. Factors associated with retention of health workers in remote public health centers in Northern Uganda: a cross-sectional study. Hum Resour Health. 2023;21(1):83. Ackers L, Ackers-Johnson J, Ssekitoleko R. Maternal mortality in low resource settings: are doctors part of the solution or the problem? The BMJ Opinion. Volume 2024. BMJ; 2018. Gajewski J, Wallace M, Pittalis C, Mwapasa G, Borgstein E, Bijlmakers L, Brugha R. Why Do They Leave? Challenges to Retention of Surgical Clinical Officers in District Hospitals in Malawi. Int J Health Policy Manag. 2022;11(3):354–61. Ackers L, Ioannou E, Ackers-Johnson J. The impact of delays on maternal and neonatal outcomes in Ugandan public health facilities: the role of absenteeism. Health Policy Plan. 2016;31(9):1152–61. Zhang H, Fink G, Cohen J. The impact of health worker absenteeism on patient health care seeking behavior, testing and treatment: A longitudinal analysis in Uganda. PLoS ONE. 2021;16(8):e0256437. Di Giorgio L, Evans DK, Lindelow M, Nguyen SN, Svensson J, Wane W, Welander Tärneberg A. Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries. BMJ Glob Health 2020, 5(12). Sheffel A, Andrews KG, Conner R, Di Giorgio L, Evans DK, Gatti R, Lindelow M, Sharma J, Svensson J, Wane W, et al. Human resource challenges in health systems: evidence from 10 African countries. Health Policy Plan. 2024;39(7):693–709. Agyeman-Manu K, Ghebreyesus TA, Maait M, Rafila A, Tom L, Lima NT, Wangmo D. Prioritising the health and care workforce shortage: protect, invest, together. Lancet Glob Health. 2023;11(8):e1162–4. United Nations Population Fund East and Southern Africa Regional Office. The State of the World's Midwifery 2022: Analysis of the Sexual, Reproductive, Maternal, Newborn and Adolescent Health Workforce in East and Southern Africa. In. South Africa; 2022. State of the world's. nursing 2020: investing in education, jobs, and leadership (SoWN). In. Geneva: World Health Organization; 2020. United Nations Population Fund. State of the World’s Midwifery 2021 (SoWMy 2021). In. New York, United States of America; 2021. United Nations Population Fund. State of the World’s Midwifery 2014 - A Universal Pathway. A Woman's Right to Health. In. New York (N.Y.); 2014. World Health Organization. State of the world’s nursing 2025: investing in education, jobs, leadership and service delivery. Geneva: World Health Organization; 2025. World Health Organization. The prevention and elimination of disrespect and abuse during facility-based childbirth: WHO statement. In. Geneva: World Health Organization; 2014. Bohren MA, Tunçalp Ö, Miller S. Transforming intrapartum care: Respectful maternity care. Best Pract Res Clin Obstet Gynaecol. 2020;67:113–26. Manu A, Zaka N, Bianchessi C, Maswanya E, Williams J, Arifeen SE. Respectful maternity care delivered within health facilities in Bangladesh, Ghana and Tanzania: a cross-sectional assessment preceding a quality improvement intervention. BMJ Open. 2021;11(1):e039616. Gryseels C, Dossou JP, Vigan A, Boyi Hounsou C, Kanhonou L, Benova L, Delvaux T. Where and why do we lose women from the continuum of care in maternal health? A mixed-methods study in Southern Benin. Trop Med Int Health. 2022;27(3):236–43. de Kok BC, Uny I, Immamura M, Bell J, Geddes J, Phoya A. From Global Rights to Local Relationships: Exploring Disconnects in Respectful Maternity Care in Malawi. Qual Health Res. 2020;30(3):341–55. Sethi R, Gupta S, Oseni L, Mtimuni A, Rashidi T, Kachale F. The prevalence of disrespect and abuse during facility-based maternity care in Malawi: evidence from direct observations of labor and delivery. Reprod Health. 2017;14(1):111. Mwasha LK, Kisaka LM, Pallangyo ES. Disrespect and abuse in maternity care in a low-resource setting in Tanzania: Provider's perspectives of practice. PLoS ONE. 2023;18(3):e0281349. Mselle LT, Kohi TW, Dol J. Humanizing birth in Tanzania: a qualitative study on the (mis) treatment of women during childbirth from the perspective of mothers and fathers. BMC Pregnancy Childbirth. 2019;19(1):231. Gavine A, MacGillivray S, McConville F, Gandhi M, Renfrew MJ. Pre-service and in-service education and training for maternal and newborn care providers in low- and middle-income countries: An evidence review and gap analysis. Midwifery. 2019;78:104–13. Munabi-Babigumira S, Glenton C, Lewin S, Fretheim A, Nabudere H. Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2017;11(11):Cd011558. Muraraneza C, Mtshali NG, Mukamana D. Issues and challenges of curriculum reform to competency-based curricula in Africa: A meta-synthesis. Nurs Health Sci. 2017;19(1):5–12. World Health Organization. World Health Assembly Resolution WHA78.16 on Accelerating action on the global health and care workforce by 2030. In. Geneva; 2025. World Health Organization. Regional Office for Africa: A decade review of the health workforce in the WHO African Region, 2013–2022: implications for aligning investments to accelerate progress towards universal health coverage. In. Brazzaville: World Health Organization. Regional Office for Africa; 2024. Organisation for Economic Co-operation and Development. Cuts in official development assistance: OECD projections for 2025 and the near term, OECD Policy Briefs. In. Paris; 2025. Center for Global Development: New Estimates of the USAID Cuts. In., vol. 2025; 2025. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1dataextractionpolicies.xlsx Additionalfile2PRISMAflowdiagram.pdf Additionalfile3otherpoliciesstrategicplansconsideringHRH.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 23 Sep, 2025 Reviews received at journal 16 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers invited by journal 05 Sep, 2025 Editor assigned by journal 03 Sep, 2025 Editor invited by journal 18 Aug, 2025 Submission checks completed at journal 15 Aug, 2025 First submitted to journal 15 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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The importance of the HWF in achieving SDG goal 3 \u0026ldquo;ensure healthy lives and promote well-being for all at all ages\u0026rdquo; is reflected in SDG target 3.c \u0026ldquo;substantially increase health financing and the recruitment, development, training and retention of the HWF in developing countries, especially in least developed countries and small island developing States\u0026rdquo; and indicator 3.c.1 \u0026ldquo;health workforce density and distribution\u0026rdquo;. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Sub-Saharan Africa (SSA) has the lowest HWF density globally with 2.5 medical doctors, and 16.4 nursing and midwifery personnel per 10 000 population in 2022, significantly below the global level of 18.7 medical doctors, and 39.4 nursing and midwifery personnel per 10 000 population. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Globally, projections suggest that by 2030 the HWF shortage will amount to approximately ten million. SSA will account for 52% of the projected global HWF shortage, missing 5.3\u0026nbsp;million health workers by 2030. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] HWF shortage is often linked to lack of investment in education, an absence of HRH policies, international migration of health workers and a weak information system monitoring the stock of the labour market dynamics to inform policies and programmes. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The COVID-19 pandemic exacerbated health worker shortages and highlighted the fragility of the health care system. Those working during the pandemic were faced with risk of infection, exhaustion, stress, and anxiety which led to compromised physical and mental health for numerous health workers, and some leaving their profession. [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Recent cuts in official development assistance (ODA) continue to affect layoffs, hiring freezes, and unpaid roles, particularly affecting frontline workers including nurses, midwives, and community health workers, and scaling back or shutting down of programmes that provided ongoing training and professional development, stalling opportunities for career growth and reducing workforce quality. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn addition to HRH shortages, evidence suggests that prior to entering the HWF, pre-service training in SSA does not always meet international standards. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The knock-on effect is reduced competence levels [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] which, in turn, affects quality of care delivered. Furthermore, inadequate remuneration packages and lack of an enabling working environment can leave health care workers demotivated and unprepared to deliver care required. [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Collectively, these factors influence health outcomes for the population. Maternal and newborn health (MNH) is one example. Under SDG 3 and the Global Strategy for Women\u0026rsquo;s, Children\u0026rsquo;s and Adolescents\u0026rsquo; Health (2016\u0026ndash;2030) there are specific targets related to MNH.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] These include ensuring women have access to family planning, antenatal care, and increasing the number of births attended by a skilled health personnel. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] As a result, essential services such as antenatal, intrapartum, and postnatal care have become more accessible with evidence suggesting increased coverage for all these services in SSA. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Access to skilled health personnel during childbirth, an indicator in the SDG framework (SDG indicator 3.1.2), increased globally from 80 to 87% between 2015 and 2024 with SSA experiencing the lowest coverage (73%) in 2024.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Despite this, high levels of maternal and newborn morbidity and mortality persist. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe World Health Organization (WHO) positioned a well-performing and competent HWF as one of the six building blocks for health system strengthening. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] To ensure the well-being of women and newborns, as well as positive health outcomes for both groups, women and newborns need access to a health system which provides timely evidence-based quality care, delivered by educated and competent midwifery care providers. However, numerous countries, including many in SSA, struggle to ensure the four essential dimensions of effective coverage applied specifically to the midwifery care health workforce namely: availability, accessibility, acceptability and quality, also referred to as the AAAQ Framework. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Box 1. provides the operational definition of the AAAQ framework dimensions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBox 1. Availability, accessibility, acceptability and quality (AAAQ) framework\u003c/b\u003e [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFramework dimensions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOperational definition\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAvailability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe sufficient supply, appropriate stock of health workers, with the relevant competencies and skill mix that corresponds to the health needs of the population.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccessibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe equitable distribution of health workers in terms of travel time and transport (spatial), opening hours and corresponding workforce attendance (temporal), the infrastructure\u0026rsquo;s attributes (physical\u0026mdash;such as disabled-friendly buildings), referral mechanisms (organizational) and the direct and indirect cost of services, both formal and informal (financial).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe characteristics and ability of the workforce to treat all patients with dignity, create trust and enable or promote demand for services; this may take different forms such as a same-sex provider or a provider who understands and speaks one\u0026rsquo;s language and whose behaviour is respectful according to age, religion, social, cultural values, etc.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe competencies, skills, knowledge, and behaviour of the health worker as assessed according to professional norms (or other guiding standards) and as perceived by users.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePersistent gaps across these dimensions have contributed to stagnating MNH outcomes, particularly in SSA[\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and threaten progress toward global targets outlined in strategies such as Every Woman Every Newborn Everywhere [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] (previously Every Newborn Action Plan[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and Ending Preventable Maternal Mortality [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]), the Global Strategy for Women\u0026rsquo;s, Children\u0026rsquo;s and Adolescents Health 2016\u0026ndash;2030[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and targets included in the SDG agenda [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. To ensure continued improvement in MNH outcomes it is important to understand how national HRH, and other national policies and strategies have evolved.\u003c/p\u003e\u003cp\u003eThe aim of this study was to examine how the elements of the AAAQ framework have been integrated and used in HRH policies and strategies related to midwifery health workforce since 2010 in four countries in SSA. The case study countries are Benin, Malawi, Tanzania and Uganda. These countries were selected to complement earlier research related to midwifery care providers\u0026rsquo; competencies after pre-service training and intrapartum competencies conducted in the same countries. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] The findings from both studies underscore critical deficiencies in midwifery health workforce knowledge and practical skills, highlighting the urgent need for comprehensive curriculum reform, as none of the reviewed training programs fully aligned with global standards. These gaps point to the necessity of sustained investment in continuing professional development and the implementation of system-level interventions to create an enabling environment for ensuring quality MNH care is accessible and available.\u003c/p\u003e\u003cp\u003eIn addition, these countries are on the WHO\u0026rsquo;s \u0026ldquo;health workforce support and safeguards list, 2023. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] Country inclusion in the list is based on a national density of doctors, nurses and midwives below the global median of 49 per 10 000 population and an universal health service coverage index below 55 (out of 100). [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides an overview of selected MNH outcomes and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides the latest available densities of medical doctors, nursing and midwifery personnel per 10 000 population for the case study countries. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSelected MNH outcomes in Benin, Malawi, Tanzania and Uganda (latest available data)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eBenin\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eMalawi\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eTanzania\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eUganda\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003eIntrapartum care\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e% of births in a health facility (15\u0026ndash;49 years) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e91.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e81.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e73.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e% of births attended by skilled health personnel\u003c/p\u003e\u003cp\u003e(15\u0026ndash;49 years) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e89.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e84.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e74.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMaternal and perinatal mortality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaternal mortality ratio per 100 000 live births (2023) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e518\u003c/p\u003e\u003cp\u003e(UI\u003csup\u003ea\u003c/sup\u003e: 393\u0026ndash;740)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e225\u003c/p\u003e\u003cp\u003e(UI: 153\u0026ndash;352)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e276\u003c/p\u003e\u003cp\u003e(UI: 192\u0026ndash;429)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e170\u003c/p\u003e\u003cp\u003e(CI:116\u0026ndash;298)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeonatal mortality rate per\u003c/p\u003e\u003cp\u003e1 000 live birth (2023) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003cp\u003e(CI\u003csup\u003eb\u003c/sup\u003e: 21\u0026ndash;38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003cp\u003e(CI:11\u0026ndash;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e21\u003c/p\u003e\u003cp\u003e(CI:16\u0026ndash;27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e18\u003c/p\u003e\u003cp\u003e(CI:11\u0026ndash;28)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStillbirth rate per 1 000 total births (2023) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003cp\u003e(CI\u003csup\u003eb\u003c/sup\u003e: 16\u0026ndash;22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003cp\u003e(CI: 12\u0026ndash;20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e19\u003c/p\u003e\u003cp\u003e(CI: 14\u0026ndash;26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e15\u003c/p\u003e\u003cp\u003e(CI: 12\u0026ndash;17)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerinatal health outcomes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e% low birthweight of all live births (\u0026lt;\u0026thinsp;2500 g) (2020) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16.4\u003c/p\u003e\u003cp\u003e(CrI\u003csup\u003ec\u003c/sup\u003e: 14.8\u0026ndash;18.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e15.6 (Crl: 14.2\u0026ndash;17.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e9.7 (Crl: 8.4\u0026ndash;11.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eData not published\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreterm birth (rate per 100 live births (\u0026lt;\u0026thinsp;37 weeks of gestation) (2020) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.9\u003c/p\u003e\u003cp\u003e(CrI\u003csup\u003ec\u003c/sup\u003e: 3.6\u0026ndash;12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e14.5 (CrI: 9.5\u0026ndash;21.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e8.4 (CrI: 4.3\u0026ndash;15.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e10.0 (CrI: 6.1\u0026ndash;16.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e. 80% CI: 80% confidence interval.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e. 90% CI: 90% confidence interval.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003csup\u003ec\u003c/sup\u003e. 95% CrI: 95% Bayesian credible interval.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003csup\u003ed\u003c/sup\u003e. For countries with no data input the low birthweight estimates are not published which was the case for Uganda.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eDensity of medical doctors, nursing and midwifery personnel in Benin, Malawi, Tanzania and Uganda (latest available data\u003c/b\u003e)[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBenin\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMalawi\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTanzania\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUganda\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e Density per 10 000 population\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical doctors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003cp\u003e(2023)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003cp\u003e(2022)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003cp\u003e(2022)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.9\u003c/p\u003e\u003cp\u003e(2022)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNursing personnel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.4\u003c/p\u003e\u003cp\u003e(2023)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.8\u003c/p\u003e\u003cp\u003e(2022)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.9\u003c/p\u003e\u003cp\u003e(2023)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.7\u003c/p\u003e\u003cp\u003e(2022)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMidwifery personnel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003cp\u003e(2023)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003cp\u003e(2022)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNot reported after 2006\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.0\u003c/p\u003e\u003cp\u003e(2022)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e. Nurses and midwives are currently dual trained In Tanzania and reported under nursing personnel.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003eVarious contextual factors, HRH policies and strategies and MNH health outcomes are present in Benin, Malawi, Tanzania and Uganda, and therefore an exploratory case-study policy process tracing approach was applied. Policy process tracing is a method that attempts to identify the underlying processes in order to explain outcomes \u0026ldquo;what mechanismic explanation accounts for the outcome?\u0026rdquo;. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] The approach aims to determine whether an independent variable(s) really affects the dependent variable(s) and to what effect. The independent variables in the study are HRH policies and strategies regarded as causes of the change in the dependent variables which are health workforce availability, accessibility, acceptability and quality.\u003c/p\u003e\u003cp\u003eWe used the READ framework for our policy process-tracing and strategy document analysis. As a systematic approach, READ provides a framework for identifying appropriate documents and gleaning relevant information from them. The stages of READ framework are: i) Ready your materials, ii) Extract data, iii) Analyse data and iv) Distil your findings. Each stage will be discussed as we outline data collection and data analysis method. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData compilation and management\u003c/h3\u003e\n\u003cp\u003eUnder the READ framework we \u0026ldquo;Readied our materials\u0026rdquo;. This required us to set parameters in terms of the nature and volume of documents we wished to identify and analyse. This was achieved by defining the following criteria:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTopic: HRH policies and strategies related to maternal and newborn health.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDates of inclusion: We opted to include documents published from 2010 to the most recent identified which was published in 2021 to explore the policy environment as prior limited national and global attention had focused on the HWF.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePlaces to search for relevant documents available in the public domain: To obtain HRH policies and strategies we searched three different sources considered most pertinent: i) the Ministry of Health website for the four countries, ii) WHO Global Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health (SRMNCAH) Policy Database (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://platform.who.int/data/maternal-newborn-child-adolescent-ageing/national-policies\u003c/span\u003e\u003cspan address=\"https://platform.who.int/data/maternal-newborn-child-adolescent-ageing/national-policies\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), and III) African Index Medicus (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.globalindexmedicus.net/biblioteca/aim/\u003c/span\u003e\u003cspan address=\"https://www.globalindexmedicus.net/biblioteca/aim/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe SRMNCAH Policy Database, a policy document repository, which contains document shared by WHO Member States including national policies, strategies, laws, guidelines, and reports that are relevant to the areas of SRMNCAH obtained during rounds of the Global SRMNCAH Policy Survey.\u003c/p\u003e\u003cp\u003eThe African Index Medicus is an international database for African health literature implemented by WHO and African partners. The key words used were human resources for health, health policies, health system, strategic plan and the country names. All sources were accessed between 6 to 8 July 2025.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOnce relevant documents were identified using the above criteria, we moved onto the second stage of the READ framework to \u0026ldquo;Extract data\u0026rdquo;. This was achieved by using an Excel spreadsheet with each column representing a category of information we wished to extract and pertinent to the AAAQ framework. Documents were closely read by two reviewers (ABM and JW) with required information extracted and added to the spreadsheet (ABM and JW) (Additional file 1_data extraction_policies).\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eOnce all relevant policy documents had been retrieved and pertinent information extracted and added to the Excel spreadsheet, we followed step three of the READ framework, \u0026ldquo;Analyse data\u0026rdquo;, an iterative process of data synthesis by reviewing the content of the documents closely and considering their purpose. Following step four of the READ framework, we then \u0026ldquo;distilled our findings\u0026rdquo;. This was achieved by mapping the relevant information from the policies and strategies to the AAAQ framework using the operational definitions to synthesise the data. Main categories were developed where possible for each aspect of the AAAQ framework. The documents were divided into two groups: i) specific HRH policy and strategic plans (overarching HRH policy/strategy) and ii) other policies and strategic plans considering HRH aligned to a broader health policy or health sector strategic plan. This was done as a very limited number of specific HRH policies and strategies are available for these countries and we wanted to explore how HRH was embedded in other policy and strategy documents which could provide critical information.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty HRH policies and strategies are included in the analysis covering the period from 2010 to the most recent identified which was published in 2021. Three policies were identified from Benin, all of which fell in the category ii \u0026ldquo;other policies and strategic plans considering HRH\u0026rdquo; as no specific HRH policy and strategy was located. From Malawi, five policies were included, one specific HRH strategy (draft) and four other policies and strategic plans. According to the literature it is documented that Malawi has an HRH Strategic Plan, 2018 to 2022 [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] however, currently it is not available in the public domain. Two HRH strategies are included from Tanzania and three other policies and strategic plans. From Uganda one HRH strategy and six other policies and strategic plans were located. Additional file 2 shows the PRISMA flow diagram charting this process.\u003c/p\u003e\u003cp\u003eBenin is the only country which does not have an overarching HRH policy and strategy, whereas Malawi and Tanzania have developed two HRH policies/strategies. Uganda recently (2021) published a new strategy covering the period from 2020 to 2030 which is a follow on to the 15-year HRH Strategic Plan 2005 to 2020 which ended in June 2020. A detailed operational plan with targets and cost is only included in the Uganda HRH strategy 2020 to 2030 with 5-year rollout operational plan for 2020/21 to 2024/25. The HRH strategies from Malawi and Tanzania included strategic objectives and implementation framework but no concrete plan on how to achieve the objectives.\u003c/p\u003e\u003cp\u003eIn addition to the overarching HRH policy and strategy each country has included aspects related to HRH in their health policy and/or health sector strategic plans.\u003c/p\u003e\u003cp\u003eAll the documents have specific reference to maternal newborn and/or infant mortality and describe concerns about continuous high levels of maternal and newborn mortality that continue to fall behind national and global targets [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Adverse outcomes such as preterm birth, low birthweight and stillbirth are not mentioned or considered in any of the documents.\u003c/p\u003e\u003cp\u003eIn terms of the AAAQ framework, all HRH specific policies addressed availability of the HWF. All HRH policies (Malawi, Tanzania and Uganda) identified a need to focus on monitoring and planning for HRH, with all referring to retention of staff as a method to increase availability. Tanzania and Uganda also commented on the need to strengthen recruitment, with Uganda also noting the importance of reducing absenteeism as mechanisms for improving availability of staff. Regarding accessibility, all HRH specific policies commented on the need for an equitable distribution of HRH staff. Acceptability was poorly represented in policies for HRH with only the Ugandan policy mentioning the need to improve acceptability but providing no further detail in terms of what this means or how to achieve it. All HRH specific policies referred to quality of HRH in terms of improving pre-service training, as well as improving continuous professional development. To achieve the former, the Tanzanian policies discussed improving training curricula, strengthening the capabilities of teaching faculty and improving accreditation for training institutions. The Ugandan document also discussed improving training curricula as well as the need to improve clinical training, standardize exams, performance and manage staff throughout their working life (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. AAAQ framework and human resources for health policies and strategic plans).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAvailability, Accessibility, Acceptability and Quality (AAAQ) framework and human resources for health policies and strategic plans\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCountry\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTitle of policy/ strategic plan/year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAvailability\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAccessibility\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eQuality\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSpecific reference to MNH\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBenin\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eNone identified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMalawi\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eMalawi Human Resources for Health Strategic Plan, 2018\u0026ndash;2022. Not available in the public domain but have been referenced in the literature [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMalawi\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman Resources for Health Strategic Plan 2012\u0026ndash;2016. Draft [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eImprove the capacity for HRH monitoring and planning.\u003c/p\u003e\u003cp\u003eImprove HRH retention.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdequate and equitable\u003c/p\u003e\u003cp\u003edistribution of HRH.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStrengthen HRH training and continued professional development.\u003c/p\u003e\u003cp\u003eSupport capacity building agendas of health training institutions.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eReduction in maternal and newborn mortality.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTanzania\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman Resource for Health and\u003c/p\u003e\u003cp\u003eSocial Welfare Strategic Plan 2014\u0026ndash;2019 [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eImprove the capacity for HRH monitoring and planning.\u003c/p\u003e\u003cp\u003eImprove HRH retention.\u003c/p\u003e\u003cp\u003eStrengthen recruitment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEquitable\u003c/p\u003e\u003cp\u003edistribution of HRH.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStrengthen HRH training and continued professional development (i.e.\u003c/p\u003e\u003cp\u003eimprove curricula for training programs and improve accreditation of training institutions).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eReduction in maternal and under five mortality.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTanzania\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNational Human Resources for Health Strategy 2020\u0026ndash;2025 [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eImprove the capacity for HRH monitoring and planning.\u003c/p\u003e\u003cp\u003eImprove HRH retention.\u003c/p\u003e\u003cp\u003eStrengthen recruitment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEquitable\u003c/p\u003e\u003cp\u003edistribution of HRH.\u003c/p\u003e\u003cp\u003eHRH recruitment in low density areas.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStrengthen HRH training and continued professional development (i.e.\u003c/p\u003e\u003cp\u003eimprove curricula for training programmes, competence-based curriculum and faculty).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eReduction in maternal and newborn mortality.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUganda\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Human Resources for Health Strategic Plan 2020\u0026ndash;2030 [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eImprove the capacity for HRH monitoring and planning.\u003c/p\u003e\u003cp\u003eImprove HRH retention.\u003c/p\u003e\u003cp\u003eStrengthen recruitment.\u003c/p\u003e\u003cp\u003eReduce absenteeism.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdequate and equitable\u003c/p\u003e\u003cp\u003edistribution of HRH.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eImproving acceptability of workforce is mentioned, but no plans or examples of how to do this are given.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStrengthen HRH training and continued professional development (i.e.\u003c/p\u003e\u003cp\u003eimprove curricula for training programmes, improved clinical training, standardized examination).\u003c/p\u003e\u003cp\u003eMaintain regular performance reviews and appraisals based on performance plans and contracts.\u003c/p\u003e\u003cp\u003eStrengthen professional associations as a mechanism for HWF empowerment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eReduction in maternal and newborn mortality.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor policies and strategies not specific to HRH, all documents from Benin, Malawi and Tanzania, and four out of the six documents from Uganda addressed availability. To improve availability, a variety of strategies were suggested including strengthening HRH planning (Benin, Malawi, Tanzania and Uganda), ensuring an appropriate supply of staff (Benin, Malawi, Tanzania and Uganda), focusing on recruitment (Benin, Malawi and Uganda) improving retention (Benin, Malawi, Tanzania and Uganda) and reducing absenteeism (Uganda). Regarding accessibility, all documents from Benin, Malawi, Tanzania and one of the six documents from Uganda mentioned improving HRH accessibility. This was discussed in terms of equitable distribution of HRH (Benin, Malawi, Tanzania and Uganda), provide health facilities with appropriate equipment (Benin), appropriate referral systems (Malawi, Tanzania and Uganda), improved access to emergency transport (Malawi), and addressing financial barriers in accessing care (Malawi and Tanzania).\u003c/p\u003e\u003cp\u003eAs with the HRH specific policies, the concept of HRH acceptability was poorly represented in other policies and strategies with no mention of the concept in the Benin policies and strategies, and only one of the four documents from Malawi addressing it. Tanzania and Uganda mentioned acceptability more consistently with all Tanzanian documents and four of the six Ugandan documents identifying the need to improve HRH acceptability. Strategies suggested for achieving this included client-centredness and being considerate of people\u0026rsquo;s personal circumstances, meeting the expectations of the population, addressing community needs, people-centred respectful care with a human rights-based approach, improving professional standards and accountability towards clients, and client charters. For each country, all documents made recommendations for improving HRH quality. Strategies included improving training (Benin, Malawi and Tanzania) and continuous professional development (Benin, Malawi and Tanzania), improving staff motivation (Benin and Malawi), accreditation of training institutions (Malawi and Uganda), performance management of staff (Tanzania and Uganda), strengthening regulatory bodies (Uganda), and ensuring staff have access to and follow guidelines and protocols (Uganda). Details provided in Additional file 3_Other policies and strategic plans considering HRH.\u003c/p\u003e\u003cp\u003eSurprisingly, the process-tracing analysis revealed that none of the policies and strategies mentioned the SDG target 3.c and indicator 3.c.1. related to the HWF. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] This signals a profound disconnect between reflecting the impact of national HRH interventions against the global accountability to the SDGs policy development framework.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFindings from the review of strategies and policies revealed potential approaches to improve the availability of the midwifery workforce including recruitment, retention and tackling absenteeism. Recruitment of health care staff would appear to be an obvious solution to HWF shortages however, reasons exist as to why this may not be possible. The level of employment in a country\u0026rsquo;s health sector is in large part determined by health labour market dynamics, not the population health needs or the health worker education capacity alone. [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] National government budgets for healthcare may not align with health care service demands, leading to an inability to recruit the required HWF. Commentary from Malawi suggests this is a real issue. Muula (2023) posits that Malawi produces hundreds of health care professional graduates annually, who if employed would resolve HRH shortages. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] Evidence suggests that improving retention of the current HWF is complex. Retention is associated with working conditions, availability of equipment and resources, ability to provide quality care, salary, opportunities for career progression, housing availability and quality (where housing is provided) as well as the feeling of being valued by colleagues. [\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] Addressing these issues is multifaceted and requires significant investment from national government.\u003c/p\u003e\u003cp\u003eReducing absenteeism to improve HRH availability was proposed in four of Uganda\u0026rsquo;s policies and strategies. However, absenteeism was not mentioned in any policy documents from Benin, Malawi, and Tanzania. Whilst acknowledging the complexity of HRH absenteeism, Ackers et al. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], go as far as saying that failure of doctors to present for work is one of the causes of maternal mortality in Uganda. Research by Zhang et al. (2021) in Uganda found a 15% absenteeism prevalence on monitored days, but this rate was higher, 42% in lower-level health clinics. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] Such absenteeism not only affects the availability of the HWF, but also the accessibility and acceptability of HRH, with absenteeism associated with lower rates of health care utilization at lower-level facilities. Whilst studies call for a crackdown on absenteeism[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], Di Giorgio et al. (2020)[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] and Ashley Sheffel et al. (2024)[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] highlight that reducing absenteeism without addressing gaps in health care worker competence would only modestly increase the average care readiness that meets minimum quality standards and the health system will continue to be ineffective. Tackling HWF absenteeism requires a greater understanding of its causes, which may include working conditions and remuneration. Addressing these factors and their interconnected effects may improve availability of the HRH workforce in SSA.\u003c/p\u003e\u003cp\u003eOur review of the strategies and policies highlighted recommendations for an equitable distribution of the health workers between rural and urban areas, as well as reductions in out-of-pocket expenditure for patients as a means of improving patient accessibility to the HWF. The unequal distribution of health care facilities and resources, including the HWF, is not a new phenomenon with these disparities widely reported in the literature.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] Similarly, suggestions for tackling these issues are not new, and have been consistently recommended in various reports and strategies for several years. [\u003cspan additionalcitationids=\"CR52 CR53 CR54\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] Realizing the ambition of an accessible HWF will require significant financial commitment from government to ensure health clinics and hospitals that are equipped with adequate and competent health workers and resources are made readily available in the most needed areas.\u003c/p\u003e\u003cp\u003eNotably, few strategies referred to improving the acceptability of HRH. This is somewhat surprising, as the literature pertaining to the importance of respectful maternity care is abundant. [\u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] Research from all four study countries indicates respectful care in the maternity setting is lacking. [\u003cspan additionalcitationids=\"CR60 CR61 CR62\" citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] Tackling disrespect and abuse in the health care setting, particularly the maternity setting, is an essential component of improving acceptability of the HWF.\u003c/p\u003e\u003cp\u003eImproving the quality of the HWF competence is imperative for better and desirable health outcomes and if quality of care is to be enhanced. The documents reviewed in this study heavily focused on the need to improve the quality of pre-service training for health care professionals as well as continuous education as a means of improving the quality of the HWF. These recommendations are valid given current evidence which suggests deficiencies in pre-service and in-service training of health care professionals contributes to a lack of a skilled HWF. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eMany of the reviewed HRH policy documents across countries were found to be repetitive, often reiterating the same challenges and proposed solutions without demonstrating clear evolution or refinement of interventions over time. For example, in Benin, the issue of \u0026ldquo;equitable distribution of HRH\u0026rdquo; within the accessibility dimension was consistently highlighted in all three national documents published between 2009 and 2018. Similarly, in Malawi, the recommendation to \u0026ldquo;improve HRH retention\u0026rdquo; under the availability dimension appeared in four separate policy documents issued between 2011 and 2022 (please refer to details in Additional file 3). Despite the repeated emphasis on these critical issues, the strategies often lacked specificity and actionable guidance on how to achieve meaningful impact. This pattern suggests a gap between policy formulation, planning and implementation, underscoring the need for evidence-informed, and results-oriented HRH strategies that offer a mix of policy solutions.\u003c/p\u003e\u003cp\u003eIt is important to acknowledge that changes in the HWF are not solely attributable to national strategic plans and policies. A range of contextual factors influence the implementation and effectiveness of these strategies, including the prevailing economic conditions, political commitment, public health emergencies such as pandemics, patterns of health worker migration, and broader HRH management practices. These factors vary significantly across settings and over time. Additionally, several of the strategies and policies reviewed in this analysis were only recently published and may not yet have been fully implemented, limiting the ability to assess their impact on workforce outcomes.\u003c/p\u003e\u003cp\u003eGaps in midwifery care providers competencies, shortages and imbalances are perhaps the most prominent bottleneck threatening the attainment of UHC and the health-related SDGs, as well as other national and global health priorities. Recognizing the HWF challenges the 78th World Health Assembly in May 2025 extend the \u0026ldquo;WHO\u0026rsquo;s Global Strategic Directions for Nursing and Midwifery 2021\u0026ndash;2025\u0026rdquo; to 2030. The resolution emphasizes the urgent need for investment in HWF education, fair remuneration, safe working conditions, and equitable distribution\u0026mdash;particularly in the context of global health emergencies, migration, and persistent workforce shortages. [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTackling the factors that influence the availability, accessibility, acceptability, and quality of the midwifery health workforce in Benin, Malawi, Tanzania, and Uganda is a complex matter. Exacerbated by inadequate data impeding strategic workforce planning by obscuring the true supply, distribution, and competencies of health professionals. Without reliable information, governments and health institutions struggle to forecast future needs, leading to mismatches between training outputs and service demands. [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] Moreover, the lack of standardized data on workforce qualifications, licensure, and continuing professional development limits the ability to monitor and assure the quality of care. In the absence of such oversight, health systems may be unable to detect or address declines in clinical competence, with direct implications for patient safety and outcomes. [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe global development landscape is facing a significant cut in ODA, with profound implications for low- and middle-income countries. According to the Organisation for Economic Co-operation and Development, net ODA is projected to decline by 9\u0026ndash;17% in 2025, following a 9% drop in 2024. [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] Latest estimates of the United States Agency for International Development assistance cuts suggest that if withdrawals stand, this could include a potential 88% cut in support to maternal and child health aid, and 94% cuts to programming for family planning and reproductive health. For the countries in our study is it estimated that the cuts as percentage of country programme will be a 58% reduction in Benin, 64% in Malawi, 38% in Tanzania and 66% in Uganda. [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/p\u003e\u003cp\u003ePowerful commitments at the highest-level, sustainable investment and agility in policy-decisions from national governments must be emphasized, regularly monitored, and reassessed to influence the centrality of health workforce development in the context of the current funding situation govern effective HWF policies and MNH health care services.\u003c/p\u003e\u003cp\u003eNewer modalities of investments in the midwifery health workforce, particularly in the quality of pre-service training, remain imperative to accelerate the transition towards universal access to quality and more acceptable and accessible MNH health care services and consequently improved MNH outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAAQ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Availability, Accessibility, Acceptability and Quality\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMNH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;maternal and newborn health\u003c/p\u003e\n\u003cp\u003eHRH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;human resources for health\u003c/p\u003e\n\u003cp\u003eHWF\u0026nbsp; health workforce\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eODA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;official development assistance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eREAD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ready your materials, Extract data, A analyse data and Distil your findings\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSDG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Sustainable Development Goals\u003c/p\u003e\n\u003cp\u003eSRMNCAH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;sexual, reproductive, maternal, newborn, child and adolescent health\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSSA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sub-Saharan Africa\u003c/p\u003e\n\u003cp\u003eUHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;universal health coverage\u003c/p\u003e\n\u003cp\u003eWHO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data used in the study are publicly available therefore ethical approval was not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll original data are publicly available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eThe authors received no funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: AB M.\u003c/p\u003e\n\u003cp\u003eData curation: AB M and JW.\u003c/p\u003e\n\u003cp\u003eFormal analysis: AB M and JW.\u003c/p\u003e\n\u003cp\u003eMethodology: AB M and JW.\u003c/p\u003e\n\u003cp\u003eWriting original draft: AB M.\u003c/p\u003e\n\u003cp\u003eWriting – review and final editing: AB M, JW, AS and MP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Mandip Aujla for her valuable review and insightful comments on earlier drafts of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBoniol M, Kunjumen T, Nair TS, Siyam A, Campbell J, Diallo K. 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In., vol. 2025; 2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Human resources for health, health policies, health workforce, policy tracing, sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-7337394/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7337394/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCentral to the achievement of the Agenda for Sustainable Development and universal health coverage is an adequate, equitably distributed and fully supported health workforce. An adequate supply of health workers who possess the needed competencies and professional attitudes can deliver evidence-based, high-quality care across all levels of the health system, thereby contributing to better health outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis study analysed how the elements of the availability, accessibility, acceptability and quality framework have been integrated and used in human resource for health (HRH) policies and strategies related to the midwifery health workforce since 2010 in Benin, Malawi, Tanzania and Uganda. We applied the READ framework for our HRH policy and strategy policy tracing analysis. The stages of READ framework are: i) Ready your materials, ii) Extract data, iii) Analyse data and iv) Distil your findings\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eTwenty HRH policies and strategies were included in the analysis. We found that all policies and strategies addressed aspects linked to availability and accessibility as well as the need for HRH quality improvements whereas acceptability was poorly represented. None of the policies and strategies mentioned the Sustainable Development Goals (SDG) target 3.c \u0026ldquo;substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States\u0026rdquo; and indicator 3.c.1 \u0026ldquo;health workforce density and distribution. Indicating a profound disconnect between reflecting the impact of national HRH interventions against the global accountability to the SDGs policy development framework.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eEfforts and investments are needed to tackle the gaps and inequalities in the availability, accessibility, acceptability and quality of the midwifery workforce. Newer modalities of investments in their quality of pre-service training, remain imperative to accelerate the transition towards universal access to quality and more acceptable and accessible maternal and newborn health care services and consequently improved health outcomes.\u003c/p\u003e","manuscriptTitle":"Human resources for maternal and newborn health in Benin, Malawi, Tanzania and Uganda: a policy process-tracing analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 17:53:32","doi":"10.21203/rs.3.rs-7337394/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-23T11:26:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-16T10:02:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184828881194057493772710496798672814951","date":"2025-09-14T05:39:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206364004016496225241942122399660360983","date":"2025-09-11T11:17:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296087648747593670818531171033398859537","date":"2025-09-06T11:44:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-05T21:54:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-03T05:10:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-18T13:31:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-15T13:22:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-15T13:18:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a5c4691-0853-4f3f-9a2e-a5f9e8cd78b1","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-15T17:53:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-15 17:53:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7337394","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7337394","identity":"rs-7337394","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}