Critical to the development and strengthening of pre-service education, advocacy may be approached using this problem-solving process. This process includes collecting evidence, involving stakeholders in planning, sharing evidence about pre-service education interventions, and planning and prioritizing interventions. Toolkit users may review all topic areas for an overview of the components of advocacy. The recently released State of the World’s Midwifery Report is an excellent advocacy document, summarizing for the first time baseline information about midwifery workforce, education, regulation and professional associations across 58 countries.

Collect evidence. There is a global shortage of 4.3 million health workers, primarily in developing countries (WHO 2006). The lack of well-trained health workers is a major barrier to implementing evidence-based interventions, such as improvements in maternal and child health, HIV/AIDS, malaria, and tuberculosis (Crisp, Gawanas and Sharp 2008; Sachs 2001). In developing countries, because maternal and child health services are the largest proportion of services used by the public, more skilled health workers are needed to supply these services (Smith and Hyre 2009). A strategy for training and deploying midwives to provide basic emergency obstetrical care is critical to reducing maternal and newborn mortality (Campbell and Graham 2006).

Involve stakeholders in planning. Successful interventions require the involvement of political leaders, including ministers, council registrars and professional association leaders (Crisp, Gawanas and Sharp 2008). To generate consensus and support, conduct meetings with key stakeholders. These meetings may be used to discuss national health priorities, present needs assessments results, and create consensus on potential programmatic approaches. The sample Stakeholder’s Meeting Agenda outlines common goals and objectives. Refer to the Stakeholder Analysis document for guidance on identifying stakeholders and planning for their potential involvement in the process.

Share the evidence to support pre-service interventions. There is ample evidence that having sufficient numbers of clinically competent health care workers directly impacts other health outcomes, including infant and maternal survival rates (WHO 2006, Sachs 2001). When controlling for other factors (e.g., income), a 10% increase in health care workers per 1000 population will lead to a 2–5% reduction in child mortality (Joint Learning Initiative 2004). Midwives, physicians, and other health care workers providing maternal and newborn care can directly reduce maternal and newborn morbidity and mortality (Joint Learning Initiative 2004).

Plan and prioritize interventions. Before determining interventions, conduct a rapid pre-service readiness assessment to obtain basic information on current priorities, needs, and capacity. Review the current human resources for health strategy or plan (if one exists), basic package of health services, and other key documents to identify national priorities. To identify and prioritize tasks currently performed by health workers of a specific cadre, analyze their competencies related to the health care needs and activities to be performed. This is often called a task analysis (See, Quality and Relevance).

Lessons Learned: Advocacy

 An analysis of the existing human resources for health plan, current national health priorities, and any other existing data on the related education program provides critical information and should be part of the needs assessment, if not done previously.

 A comprehensive list of national stakeholders is critical, including adequate representation from those who control policy, educational decisions, and labor laws. To design a relevant program, identify stakeholders who have on the ground practical experience.

 Assessment or research data is extremely helpful in convincing key stakeholders to take action or support a plan of action.