GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY Review

Transcription

1 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY 2013 Review

2 WHO Library Cataloguing-in-Publication Data Global Advisory Group on Nursing and Midwifery: 2013 review. I.World Health Organization. ISBN Subject headings are available from WHO institutional repository World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site ( or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: ; fax: ; bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press through the WHO web site (www. who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. WHO is not responsible for the views expressed in this publication. Design & layout by L IV Com Sàrl, Villars-sous-Yens, Switzerland. Printed by the WHO Document Production Services, Geneva, Switzerland.

3 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW CONTENTS ACKNOWLEDGEMENTS ABBREVIATIONS AND ACRONYMS EXECUTIVE SUMMARY INTRODUCTION Methodology FINDINGS Technical expert groups and panels Global Advisory Group on Nursing and Midwifery (GAGNM) Strengthening the efficiency and effectiveness of the GAGNM Key informant perspectives SUGGESTIONS FOR INCREASING THE CONTRIBUTION THE GAGNM MAKES Ten strategies to boost GAGNM s role CONCLUSION REFERENCES The GAGNM meeting reports ANNEX A: WHA45.5 STRENGTHENING NURSING AND MIDWIFERY IN SUPPORT OF STRATEGIES FOR HEALTH FOR ALL ANNEX B: KEY INFORMANTS IN THE REVIEW PROCESS ANNEX C: WHO GAGNM INTERVIEW GUIDE ANNEX D: DEVELOPMENT OF GAGNM TERMS OF REFERENCE

4 ACKNOWLEDGEMENTS Many individuals participated in the interviews undertaken in this review of the WHO Global Advisory Group on Nursing and Midwifery and their contribution enriched the preparation of this report. The participation of Regional Advisers for Nursing and Midwifery namely; Fariba Al- Darazi, Kathlyn Fritsch, Margaret Phiri and Prakin Suchaxaya is greatly appreciated and those who commented on the draft report; Silvia Cassiani and David Benton. The review and the preparation of the draft report was carried out by Judith A Oulton, a nurse, Senior Associate with ICS Integrare, former Chief Executive Officer of the International Council of Nurses and of the Florence Nightingale International Foundation. She served as a founding board member of the Global Health Workforce Alliance. Annette Mwansa Nkowane, Technical Officer, Department for Health Policies and Workforce (HPW), coordinated the conceptualization, preparation and finalization of this review. Editing: Vivien Stone, Crowborough, East Sussex, UK Layout and design: L IV Com Sàrl, Villars-sous-Yens, Switzerland 2

5 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW ABBREVIATIONS AND ACRONYMS GAGNM HRH HFA ICM ICN IDRC ILO KI MDG PHC RCN RNA TOR UNFPA WHA Global Advisory Group on Nursing and Midwifery human resources for health Health for All International Confederation of Midwives International Council of Nurses International development Research Centre (Canada) International Labour Organization key informant Millennium Development Goal primary health care Royal College of Nursing (United Kingdom) Regional Nursing Adviser terms of reference United Nations Population Fund World Health Assembly 3

6 EXECUTIVE SUMMARY The World Health Organization began a review of the Global Advisory Group on Nursing and Midwifery (GAGNM) in This review examined and provided suggestions on how to strengthen the GAGNM; in particular determining optimal ways to improve its utility and effectiveness. The process involved a literature review and 24 key informant interviews. The key informants included current and former GAGNM members at WHO headquarters working on nursing and midwifery, Regional Advisers for Nursing and Midwifery and a director of human resources for health (HRH) and observers. The GAGNM has existed for more than two decades and was designed to serve as a strategic, action-oriented body providing policy advice to the Director-General to strategically enhance the contributions of nursing and midwifery within the context of all WHO priorities and programmes. Its establishment is enshrined in WHA Resolution 45.5 which urged WHO to establish a global multidisciplinary advisory group on nursing and midwifery. This is further supported by WHA resolutions and The review revealed that the terms of reference (TOR) continue to be relevant and important today, though achievements related to them have been limited. All five TOR listed below were deemed highly important. The greatest achievement was in TOR 5 while least progress was seen in TOR 3. GAGNM terms of reference 1. To guide the development of the global agenda for nursing and midwifery within the overall health agenda. 2. To provide policy advice on how the responsiveness of health systems to people s health needs can be optimized through the effective use of nursing and midwifery services that are based on research as scientific evidence. 3. To support the development and use of nursing and midwifery outcome indicators in relation to health gains and health status. 4. To participate in resource mobilization and efforts for the effective implementation of the global agenda for nursing and midwifery. 5. To collaborate in establishing mechanisms for monitoring the progress of nursing and midwifery contributions to the health agenda and to the implementation of the global agenda for nursing and midwifery. Key informants firmly believe in the importance of the GAGNM and feel it has several benefits for WHO, the professions and the public including providing: global recognition/visibility; a policy voice; advocacy for strengthening nursing and midwifery and commitments to them; a network of influential individuals; opportunities to be up to date on global issues and WHO priorities and actions; and the opportunity to help craft WHO products. As one key informant stated: IT WOULD BE A DISASTER FOR HEALTH PROFESSIONS IF NURSING AND MIDWIFERY WERE GONE FROM WHO. Factors influencing the scale of GAGNM s support to WHO relate to financial resources and group leadership. A number of suggestions for improving the effective and efficient functioning of the group and its contributions are outlined later in this report. 4

7 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW INTRODUCTION As part of the reform process and the drive to increase efficiency, effectiveness and coordination, the World Health Organization (WHO) is integrating its work on HRH more closely with its broader health systems agenda. This involves reviewing the various mechanisms for providing technical support to WHO, such as the GAGNM and the Technical Expert Panel on Nursing and Midwifery in some regional offices. To that end, this review was commissioned late in 2012 to: examine and provide suggestions on strengthening the Technical Expert Panel and GAGNM; in particular to determine optimal ways to improve their utility and effectiveness. The GAGNM has existed for more than two decades. In 1992 the growing concern for ensuring adequate nursing and midwifery services worldwide led the World Health Assembly (WHA) to adopt Resolution WHA45.5: Strengthening nursing and midwifery in support of strategies for health for all (1992) (see Annex A). Specifically, the resolution requested the WHO Director- General to establish an interdisciplinary global advisory group to advise the Director-General regarding: a) Developing mechanisms for assessing national nursing and midwifery service needs; b) Assisting countries with the development of national action plans for nursing and midwifery services, including research and resource planning; and c) Monitoring progress in strengthening nursing and midwifery in support of strategies for health for all. (WHA, 1992) The GAGNM serves as a strategic, action-oriented body providing policy advice to the Director- General and the WHO Cabinet to strategically enhance the contributions of nursing and midwifery within the context of all WHO priorities and programmes. It has been mandated to: Guide the development of the global agenda for nursing and midwifery within the overall health agenda; Provide policy advice on how the responsiveness of health systems to people s health needs can be optimized through the effective use of nursing and midwifery services that are based on research as scientific evidence; Support the development and use of nursing and midwifery outcome indicators in relation to health gains and health status; Participate in resource mobilization and efforts for the effective implementation of the global agenda for nursing and midwifery; and Collaborate in establishing mechanisms for monitoring the progress of nursing and midwifery contributions to the health agenda and to the implementation of the global agenda for nursing and midwifery. Methodology Document and web site reviews and key informant (KI) interviews formed the basis of information gathering. The interview guide for key informants can be found in Annex C. A request for interviews was sent to 37 individuals. Of these, 24 (65%) agreed to participate. Key informants consisted of current and former GAGNM members, the WHO focal point for nursing and midwifery, WHO Regional Advisers for Nursing and Midwifery and a WHO director for HRH and observers. WHO documentation relating to the GAGNM and nursing and midwifery technical groups is limited. Reports from face-to-face meetings which have been registered in the WHO archives were accessed while others were obtained through the International Council of Nurses (ICN) and the WHO Western Pacific Regional Office. Because of the dearth of information on the technical groups, these are not dealt with in any depth. 5

8 FINDINGS Technical expert groups and panels According to the ICN publication, 60 years of collaboration. The International Council of Nurses and the World Health Organization, the first expert committee was appointed in 1950 to address the global nursing shortage while the second session, in 1951, focused on numbers of nurses and their education (ICN, 2009). The 1959 report of the fourth meeting notes that the third session centred on nursing administration while the meeting of the previous year was concerned with nurses preparation and roles in public health (WHO, 1959). The next expert committee was convened eight years later and focused on the needs of nursing service (WHO, 1966). Three other expert meetings were held: one in 1974 which dealt with community nursing; one in 1983 addressing education and training of faculty and managers in relation to primary health care; and one in 1995 which focused on primary health care (ICN, 2009). In addition, the Study Group on Nursing Beyond the Year 2000 met in 1994 to consider ways in which the roles and functions of nurses and midwives would need to change to meet health care needs in the new millennium (WHO, 1994). The first decade of the 21st century saw a number of consultative meetings. No minutes of meetings are available and there is little other documentation thus it is difficult to accurately assess the contribution of the GAGNM. However, it appears that, at minimum, the following occurred: 2007: a stakeholders meeting on nursing and midwifery contributions to achieving the Millennium Development Goals (MDG); 2007: joint global consultation hosted by the International Confederation of Midwives (ICM), ICN, WHO and the Government of Pakistan on strengthening nursing and midwifery; 2006/2007: Task Force on Global Standards in Nursing and Midwifery which contributed to the development of the 2009 publication on global standards for the initial education of professional nurses and midwives; and 2008: multidisciplinary high-level group on the renewal of primary health care (PHC) to provide GAGNM with evidence-based expert advice on policy and models for strengthening health systems through PHC. Global Advisory Group on Nursing and Midwifery (GAGNM) The establishment of this group in 1992 was hailed by the nursing and midwifery community as clear evidence of their importance to WHO and health care in general. It provided direct access to the WHO Director-General and the global nursing leadership approached it with optimism and high expectations. The terms of reference were set in 1992 and were amended in 1997, 1999 and 2010 (see Annex D). Aside from the 1997 TOR, the other sets are very similar in relation to providing policy advice on how nursing and midwifery contributions can be optimized in meeting people s health needs; supporting the development of nursing and midwifery outcome indicators; participating 6

9 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW in resource mobilization and collaborating in monitoring progress of nursing and midwifery contributions to the health agenda. Those for 1992 and 1999 are nearly identical and were used as the basis for the key informant interviews. The TOR were examined through a document review and the views of key informants who were asked to rate them on both importance and achievement. Their continued importance and relevance today were clearly affirmed in the interviews. Achievement, however, was much less so. TOR 1: TO GUIDE THE DEVELOPMENT OF THE GLOBAL AGENDA FOR NURSING AND MIDWIFERY WITHIN THE OVERALL HEALTH AGENDA Document review: from as early as the first meeting, documents illustrated GAGNM s interest in setting the nursing agenda globally, and in encouraging clear national agendas as well (GAGNM, 1992). The group played a key role in setting the global agenda through its strong participation in the development of the Nursing and Midwifery Strategic Directions and (GAGNM 1992, 1993, 1994, 1995, 2001, 2008). Minutes of various GAGNM meetings support the view that nursing and midwifery must be considered within the context of, and be seen as contributing to, the broader WHO agenda. At the same time the group recognized the tension between this aim and the pull to focus on a more silo approach. Early on the GAGNM agreed that both were important. To ensure members were knowledgeable about WHO programmes and priorities presentations by other WHO departments were a major aspect of GAGNM meetings by the late 1990s. As an example, in 2000, presentations were made on the World Health Report, human resources for health, macroeconomics, HIV, maternal child health, and mental health. Reports by Regional Advisers for Nursing and Midwifery, ICM, ICN, International Labour Office (ILO) and the United Nations Population Fund (UNFPA) as well as the Chief Nursing and Midwifery Scientist provided members with trends, issues and priorities for WHO and nursing and midwifery in general (GAGNM, 2000). At times, this focus on WHO initiatives seemed to be overwhelming the meetings and there appeared to be an over emphasis on listening and not on engaging or in determining how nursing and midwifery could contribute in these areas. Key informant perspectives: respondents were asked to rate the TOR on the basis of importance and achievement where: 1 not well; 2 somewhat well; 3 well; or 4 very well. It should be noted that two key informants chose not to reply while another three responded to some aspects only. No one considered this mandate unimportant 86% of key informants (19/22) viewed it as highly important. There was less unanimity in terms of achievement. Of the 20 commenting on achievement, one individual felt the TOR had not been achieved and another nine deemed it only partially successful. An equal number were more optimistic with eight considering it achieved and two highly so. 7

10 Figure 1. TOR 1: Guide the global nursing and midwifery agenda Not important/achieved Somewhat important/achieved Important/achieved Highly important/achieved Importance Achievment Comments included the following: The GAGNM made recommendations to WHO, however most were not acted on; and People didn t understand the GAGNM in-house the same was true for nursing and midwifery, which still continues to struggle for a niche. It is imperative to use terms that highlight the importance of GAGNM and its contribution to make GAGNM more visible. TOR 2: TO PROVIDE POLICY ADVICE ON HOW THE RESPONSIVENESS OF HEALTH SYSTEMS TO PEOPLE S HEALTH NEEDS CAN BE OPTIMIZED THROUGH THE EFFECTIVE USE OF NURSING AND MIDWIFERY SERVICES THAT ARE BASED ON RESEARCH AS SCIENTIFIC EVIDENCE Document review: recommendations by the GAGNM to WHO repeatedly emphasized the need for better utilization of the nursing and midwifery professional cadre. Many of the recommendations are quite general in their wording though some suggest actions such as finding funds for demonstration projects and case studies to evaluate the impact and cost-effectiveness of nursing and midwifery services in country priority areas (GAGNM, 2009). The work done recently through the GAGNM to showcase the nursing and midwifery contributions to PHC is an excellent example of this. At the same time, one area, which has been reiterated from the beginning, is the importance of the contribution nursing and midwifery can make in relation to policy development. Calls as early as 1992 were for the Coordinating Committee on Nursing and Midwifery at WHO headquarters to assist in better utilization/inclusion of nursing and midwifery in policy and work (GAGNM, 1992). In 1994 the GAGNM called for WHO to encourage WHO country representatives to include nursing and midwifery regional input into WHO/country plans and ensure nursing and midwifery personnel were included in country assessment teams, and for regional directors to provide a forum for government chief nursing and midwifery officers to share knowledge and experience and thereby increase their capacity to provide policy input into ninth programme of work (GAGNM, 1994). In 2000 the GAGNM asked WHO to ensure nursing and midwifery input in the development of WHO policies and programmes at all levels, and encourage Member States to open up their own policy-making processes to nursing and midwifery inputs (GAGNM, 2000). Key informant perspectives: as with the previous TOR, all considered this mandate important with 20 of the 21 deeming it highly important. Fewer however, felt it had been achieved. Some 20% felt it was not achieved while another 40% believed it to be only somewhat achieved. 8

11 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW Figure 2. TOR 2: Provide policy advice Not important/achieved Somewhat important/achieved Important/achieved Highly important/achieved Importance Achievement Comments included the following: Although reports and recommendations were made, there were no resources for the WHO Secretariat to implement recommendations; and The GAGNM contribution is always overlooked at WHO due to rules and regulations. Even when suggestions are made it takes time to reach the WHA (for example, PHC was a very important issue but there was no feedback on GAGNM s work in this area). TOR 3: TO SUPPORT THE DEVELOPMENT AND USE OF NURSING AND MIDWIFERY OUTCOME INDICATORS IN RELATION TO HEALTH GAINS AND HEALTH STATUS Document review: this item has been part of the GAGNM mandate since 1992 and in both that year and 1993 the need was noted, yet there is little attention accorded to it in the documents reviewed (GAGNM, 1992, 1993). In 2000 the GAGNM recommended to WHO that strategic alliances be formed to identify uniform, core indicators; that WHO build evidence regarding cost-effective nursing and midwifery services and their impact on priority diseases; and that core nursing and midwifery indicators be included as part of regional surveillance systems that monitor country-level health status (GAGNM, 2000). Again, in 2001, the GAGNM observed that a minimum set of core indicators was needed and should be built on existing monitoring systems, especially those of WHO (GAGNM, 2001). Four years later the WHO Secretariat staff reported having done some exploratory work on the establishment of a global nursing database. In 2007 staff reported on collaboration with Health Canada, the University of Toronto Faculty of Nursing and Regional Nursing Advisers (RNA) in a global survey to determine the minimum data set required to monitor the health workforce, including specifics for nursing and midwifery and that analysis of the data collected was on course (GAGNM, 2007). The Strategic Directions called for uniform indicators and systems for monitoring human resources levels, and, additionally, core indicators for each key result area and data collection to monitor gains and losses (WHO, 2002). The Strategic Directions contains a reference to the need for indicators that support evidence-based policy and practice. Key informant perspectives: this TOR was also considered very important though two individuals felt it was less so. In terms of achievement, however, few felt it was achieved. None believed it was highly achieved and only 15% viewed it as achieved. 9

12 Figure 3. TOR 3: Nursing and midwifery outcome indicators Not important/achieved Somewhat important/achieved Important/achieved Highly important/achieved Importance Achievement Comments included the following: There had been no discussions on how to measure these indicators. There is need for new models to measure outcomes worldwide; People need to understand what they are and how they could contribute; Indicators already exist in WHO and relevant ones could be used for nursing and midwifery; Although indicators are suggested in the Strategic Directions for Strengthening Nursing and Midwifery, they need to be fine-tuned and this is not easy for the GAGNM; and Implementing these indicators would require a lot of resources. TOR 4: TO PARTICIPATE IN RESOURCE MOBILIZATION AND EFFORTS FOR THE EFFECTIVE IMPLEMENTATION OF THE GLOBAL AGENDA FOR NURSING AND MIDWIFERY Document review: this TOR is the least documented apart from requests that WHO increase resources for nursing and midwifery in general. This request was repeatedly made. It was positively responded to in 1992 and 1993 when both funding and staff to work on nursing and midwifery were provided. In 1994 the GAGNM recommended that nursing and midwifery staffing in WHO be reviewed. Nearly every time the GAGNM met there was a recommendation that the Director-General, directly or through the regional directors or Member States, ensure sufficient nursing and midwifery personnel were in place. There is no indication that financial resources were requested from other sources and it is not clear whether the GAGNM played a role in securing funding ( ) to monitor the extent to which the WHA Resolution 45.5 strategies had been implemented in Member States. In 1994 it was recorded that the Royal College of Nursing (RCN), United Kingdom, helped develop fundraising materials for nursing and midwifery but there is no further reference to this or to how the materials were used (GAGNM, 1994). GAGNM minutes from 1997 reported that nursing and midwifery staffing levels in WHO were decreasing and in 2008 the WHO Secretariat reported to the GAGNM that it no longer had sufficient resources to continue to support GAGNM. However, no discussion about how to address this was recorded (GAGNM 1997, 2008). The issue of resource mobilization is not addressed in the Strategic Directions for Strengthening Nursing and Midwifery though the current document captures resource needs in relation to competing for research funding and the need for mobilizing financial resources to increase investment in educational institutions (Strategic Directions for Strengthening Nursing and Midwifery ). However, none of these relate to GAGNM s role. 10

13 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW Key informant perspectives: over 95% of respondents saw resource mobilization as important with 77% viewing it highly important. One informant felt it was not important. In terms of achievement, this activity was rated as the least well achieved: four felt it was achieved; eight said it was not achieved and ten felt it was somewhat achieved. No one felt it was highly achieved. Figure 4. TOR 4: Resource mobilization Not important/achieved Somewhat important/achieved Important/achieved Highly important/achieved Importance Achievement Comments included the following: Some GAGNM members attempted to work with the ICN but not much was achieved; There are no fund raising activities at regional or country level; and Most Member States do not know what is going on globally. They could make more use of the GAGNM. The GAGNM could advocate for funding at country level. TOR 5. TO COLLABORATE IN ESTABLISHING MECHANISMS FOR MONITORING THE PROGRESS OF NURSING AND MIDWIFERY CONTRIBUTIONS TO THE HEALTH AGENDA AND TO THE IMPLEMENTATION OF THE GLOBAL AGENDA FOR NURSING AND MIDWIFERY Document review: while this activity was not on every agenda of the GAGNM it was an item receiving regular attention, beginning with the International Development Research Centre, Canada (IDRC) funded study. The 1994 meeting was concerned with monitoring the implementation of national action plans but there is no follow-up recorded (GAGNM, 1994). In general, monitoring seemed to occur in advance of progress reports to the Executive Board and WHA and mechanisms themselves were not directly addressed. In 2002 the WHO Secretariat reported work was underway to develop a framework for monitoring of goals of Resolution WHA54.12: Strengthening nursing and midwifery (2001) (GAGNM, 2002). In 2005 the need to monitor progress on the Strategic Directions for Nursing and Midwifery was noted in the meeting and staff reported that the WHO Secretariat had undertaken some exploratory work on developing a global nursing database (GAGNM, 2005). Resolution WHA59.27 Strengthening nursing and midwifery (2006) urged Member States to collect and use core nursing and midwifery data and in 2007, as noted earlier, WHO headquarters reported on its collaborative work with Toronto University, Faculty of Nursing, Canada. The goal was to complete a global survey to evaluate progress in strengthening the nursing and midwifery workforce using the five key result areas and standardized indicators (GAGNM, 2007). The report, published in 2010, is based on the responses of 77 Member States. As the GAGNM has not met since the report was released, there has been no opportunity for the group to address it. 11

14 Key informant perspectives: Of the 22 respondents, two felt it was somewhat important while five deemed it important and 15 highly important. Respondents were nearly evenly split in terms of achievement. While none found it highly achieved, 55% saw it as achieved. Among the 45% less positive, one third saw it as not achieved. Figure 5. TOR 5: Monitoring nursing and midwifery contributions Not important/achieved Somewhat important/achieved Important/achieved Highly important/achieved Importance Achievement Comments included the following: Regional Advisers for Nursing and Midwifery tried to monitor contributions Many of these activities were carried out by the focal point for nursing and midwifery at WHO headquarters rather than through GAGNM. Strengthening the efficiency and effectiveness of the GAGNM This review considered how to strengthen the efficiency and effectiveness of the GAGNM. These are key factors in assessing the performance of any group or organization. Efficiency is about performance about undertaking a task with least wasted time and effort about doing something in the right manner. Effectiveness is about achievement about results or doing the right thing. In terms of the GAGNM, the aim is to be efficiently effective doing the right thing in the right manner. FACTORS AFFECTING EFFICIENCY The literature shows common features when considering factors that promote efficiency. They relate to having the right information, resources and support to do the job and include: Capable leaders and managers; Clear, shared direction, goals and priorities; Knowing one s role and its limits, especially in terms of authority and control; Understanding the roles of others; Clear support from managers and senior officials; Effective communications and feedback; The right information at the right time; Time to do the work well; Having the human and financial resources to get the work done; Access and expertise in using technology to get the work done; Clear reporting processes. 12

15 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW FACTORS INFLUENCING EFFECTIVENESS Decades of research on teams and work effectiveness demonstrate that many of the factors that influence efficiency also affect effectiveness. You can only reach your destination if you know where you are headed and have the ability (knowledge, skills, resources, etc.) to get there. For groups such as the GAGNM it is about having: Clear, shared understanding of the task at hand; The authority to undertake the work; Competence (knowledge, skills) to be successful; Sufficient, reliable and readily available information; The resources and support to get the job done; Understanding of the rules and protocols that must be observed; Access to decision-makers. DOCUMENT REVIEW Several of the factors affecting efficiency and effectiveness appear in the minutes of the GAGNM meetings, particularly in the later years. The energy, accountability and action of the first four meetings are clear. The first meeting noted the expectations that the GAGNM would meet annually with provision for rotation and continuity; subgroups would undertake specific tasks and monitor progress; and the GAGNM would be supported at WHO headquarters by a Coordinating Committee on Nursing and Midwifery. Support was evident and there was action and feedback on the recommendations of the group to the WHO Director-General. The picture that emerges at the end of the 1990s, however, is one of a gradual waning interest in and support of the GAGNM. PRESENCE AND INTEREST OF THE DIRECTOR-GENERAL The WHO Director-General was clearly evident and supportive in the first years of the GAGNM. The Director-General opened the first four meetings and took clear action on GAGNM recommendations, including provision of additional funding and human resources and correspondence with regional directors to elicit their support. In the following two meetings another official opened the event but the Director-General gave a short address at some point. However, from 2005 onwards the Director-General usually received a delegation from the GAGNM who presented the recommendations arrived at during the GAGNM meeting. SELECTION AND ENGAGEMENT OF THE GAGNM CHAIR AND MEMBERS The selection of GAGNM members involves the active participation of WHO regional offices. Based on established criteria, three curricula vitae are sent from each of the regions to WHO headquarters. These are then scrutinized and acceptable candidates interviewed by at least two directors from priority programmes and someone representing the Director-General s office with the participation of the focal point for nursing and midwifery. At least two candidates are selected from each of the WHO regions to serve for a period of three years. The GAGNM then selects the Chair and Vice-Chair from among themselves. Continuity is assured by the presence of Regional Advisers for Nursing and Midwifery and some observers, such as the ICM and ICN, all of whom have the right to participate fully. At one point the minutes show a concern about the lack of nursing representation for some regions because a non-nurse/midwife had been appointed (i.e. a representative of another professional group was present since the GAGNM was meant to be multidisciplinary in its composition). In 1997 GAGNM members received from WHO a modus operandi which spelled out the frequency of meetings and indicated that the Chair would meet the Director-General before the meeting, and that the Chair, appointed by the Director-General, would stay for three years initially. While several other aspects, such as working via subgroups, were covered, there is no reference 13

16 to the role of staff in relation to the GAGNM (GAGNM, 1997). The next changes to the modus operandi were introduced in 2001 and the frequency of meetings changed from biennially to annually. They spelled out the composition of the group, the tenure and requisite skills of the Chair, a code of conduct for members and communication strategies. It also stated that there would need to be a regularly updated action plan. MEETINGS Meetings were initially held annually. This changed in 1997 to biennially and then in 2001 to annually. From the beginning the meeting used a combination of plenary and group sessions. Groups often made recommendations on their group topics but there is no record of where these went or if they were ever acted upon. As noted earlier, presentations by other departments of WHO began in 1997 and by 2000 had taken over as the main focus of the meetings leaving little time for a GAGNM agenda. This was the opinion of several key informants who expressed concerns that GAGNM was not being appropriately consulted. STRATEGIC PLANNING From the outset the GAGNM has been focused on ensuring a strategic plan. For example, in the first meeting, a subgroup was formed to assist in developing both the strategic and action plans for implementing Resolution WHA 45.5: Strengthening nursing and midwifery in support of strategies for health for all (1992) and assisting with agenda development for 1993 (GAGNM 1992). From 2002 onward the strategic plan has been for nursing and midwifery in general. It has been seen as important to have a global plan which is widely shared and which can guide the activities of others, including WHO regions and Collaborating Centres. The lack of GAGNM plans (though there were to be regularly updated action plans as of 2001) means the GAGNM was not monitoring general progress to the extent it might have. However, monitoring of WHA resolutions did occur though with limited Member State participation. As one key informant noted: Issues such as strategic planning for nursing were given very limited time and we received these documents as FYI,(for your information) Discussions tended to be more operational in nature as opposed to advisory. SUPPORT TO THE GAGNM A Coordinating Committee on Nursing and Midwifery, made up of headquarters staff, was set up in 1992 with a mandate to ensure nursing and midwifery services were included in WHO policy formulation and programme implementation and that programme areas made optimal use of nursing and midwifery experts for suitable vacancies and technical input to their work. A headquarters coordinating subgroup reviewed post descriptions for vacant and reclassified posts to determine those where duties could also be carried out by health professionals other than physicians and post descriptions were altered to reflect this (GAGNM, 1992). It is not clear when the committee and this function ceased to exist but a lack of nursing and midwifery voice in WHO was a frequent complaint in later years. In 2000 it was noted that the GAGNM should assist in reinstating the committee that reviews all vacancy notices in order to ensure that posts are open to different disciplines, especially nurses and midwives as opportunities for them to fill WHO posts had declined (GAGNM, 2000). Information flow from staff to members clearly represented a problem by At that meeting members commented that they could be better prepared for meetings if they could receive a full set of reference and background reading material well in advance of the meeting. At the same time the need for GAGNM support for nursing and midwifery was emphasized. Members were told they must think about how their recommendations would be implemented and how the GAGNM could support the implementation process (GAGNM, 2002). 14

17 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW By 2005 there is an increased sense of waning support for the GAGNM. A new informal broader stakeholder group was created and met in advance of the 2007 GAGNM meeting. Although GAGNM members attended this, the group seemed to have no part in its establishment though the stakeholder group made recommendations to the GAGNM. According to the minutes of the larger meeting, its purpose was to seek broad-based individual and organizational input to the global action plan for nursing and midwifery; and to seek advice on collaborative actions related to the MDGs including nursing and midwifery strategies for strengthening the workforce response to attain the MDGs (Stakeholders meeting, 2005). The 2007 the GAGNM meeting was also where the WHO nursing and midwifery focal point announced it no longer had adequate resources to support the GAGNM and offered no solutions other than decreasing the length of GAGNM meetings from three to one and a half days to accommodate the new stakeholder group. Other changes such as the fact that on previous occasions the Director-General personally attended the meeting and addressed the group were also noted. In spite of all this, it was noted that regions had high expectations of the GAGNM. Members raised a number of points: The need for information to be disseminated ahead of the meetings, using appropriate technology and regularly shared through the WHO nursing and midwifery focal point at headquarters and regional web sites; GAGNM meetings should occur once a year for three days and be open to observers and not associated with the stakeholders meetings; Virtual GAGNM meetings should take place throughout the year; The WHO Secretariat was asked to prepare a position paper on the support needed to function effectively; A reciprocal interregional link between GAGNM members and the Regional Advisers for Nursing and Midwifery should be established to allow everyone to keep in touch and inform each other of key issues and activities within the regions; A page for the GAGNM could be established on the WHO nursing and midwifery global web site for information on scheduled conferences or meetings of interest to GAGNM members; WHO Secretariat should prepare a package for GAGNM members to use in promoting the group as few people are aware of its existence and/or its functions; A theme should be established for each meeting, such as primary health care, pandemics, etc.; Electronic meetings should occur every three months using various technologies/ methods; There had been too few briefing papers circulated prior to the meeting, the agenda and papers had not been circulated sufficiently ahead of time and there had not been enough advance notice given for any of the meetings. It was suggested that the GAGNM set a schedule of dates for the year, including dates for teleconferences, etc.; Meeting papers should be sent two months before the meeting, either electronically or as printed copy; Regular contact should be made with members, at least on a quarterly basis; WHO Secretariat should keep the GAGNM informed of staffing challenges such as the lack of secretarial support. This would enable them to understand the context within which the WHO focal points for nursing and midwifery at global and regional levels are operating and to be more supportive; Anyone who agrees to become a member of the GAGNM should be prepared to work on documents and/or other materials and send them to the WHO Secretariat for sharing with other members; and A transitional phasing of new members into the GAGNM was suggested. With one third of the group being appointed at any one time, it would provide an overlap of experienced members with new members. The list demonstrates the general discontent of the group and the perceived lack of support. There was no recorded follow-up to this in the next meeting and no recommendations concerning GAGNM needs were presented to the Director-General. 15

18 During the 2010 meeting members were surveyed to determine the scope of their involvement; it is unclear where the impetus for this originated; i.e. from GAGNM members or staff though it was a GAGNM non-nurse member who made the presentation. The results showed that, overall, the establishment of the GAGNM was viewed as a major development for the nursing profession which had so far made a significant contribution in putting nursing in the forefront. The TOR were still considered valid though achievement on them needed to be monitored by defining both quantitative and qualitative indicators to include the preparation of strategic plans for nursing and midwifery to help countries implement changes. Documentation of the role of the GAGNM was seen as very important. Such documentation should include the role of the GAGNM in strengthening nursing and midwifery globally in collaboration with WHO and partners and nursing and midwifery work in partnership with stakeholders to strengthen health systems. The GAGNM is an opportunity that should not be questioned. The respondents to the 2010 questionnaire put forward the following suggestions: WHO to encourage and ensure active participation and stronger input of GAGNM members; The GAGNM should be more assertive and play a more effective role in influencing health policy; Clarity on the objectives of the annual GAGNM meeting is needed; Open discussions on GAGNM-related matters and on specific issues such as: disparities in nursing and midwifery around the world, progress to achieve MDGs and communication; Document obstacles faced and success stories on strengthening nursing and midwifery through the GAGNM; The GAGNM should work more closely with RNAs and this should be documented; Clarify the GAGNM s external and internal roles. The GAGNM should be heard outside WHO in the media, national bodies etc.; The GAGNM should monitor how WHO used and (uses) the advice provided by it; and WHO should call on the GAGNM between meetings (GAGNM, 2010). A presentation was also made on optimizing GAGNM s role in health policy change and health system strengthening at all WHO levels. It was noted that considerable fragmented work is being done, all of which needs to be linked to the overall WHO agenda, the Strategic Directions on Nursing and Midwifery and the Global Programme of Work. In the ensuing discussion the need for a new model describing what the GAGNM does should be developed and showing linkages to WHO efforts to strengthen nursing and midwifery (GAGNM, 2010). Unfortunately these discussions did not form part of the recommendations to the WHO Director- General (recommendations are supposed to be agreed upon before being sent by the Chair directly to the Director-General). Key informant perspectives EXTENT TO WHICH THE GAGMN HAS MET ITS OBJECTIVES Key informants were asked how far the GAGNM had met its original objectives when it was set up. GAGNM was created in 1992 as a strategic, action-oriented body providing policy advice to the Director-General and the WHO Cabinet to strategically enhance the contributions of nursing and midwifery within the context of all WHO priorities and programmes. The graph below shows the extent to which GAGNM met its objectives. 16

19 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW Figure 6. Extent to which the GAGNM has met its objectives Meeting objectives Somewhat well Well Very well * Nobody made a comment for not important/achieved therefore variable not included in the pie chart. RATIONALE FOR RANKINGS Key informants were next asked to provide the reasons for the rankings they had given regarding how well GAGNM had lived up to its aims. Poor rankings relate to factors affecting efficiency and effectiveness; namely the large number of people (usually there would be 12 GAGNM members, five or six observers, six WHO Regional Advisers for Nursing and Midwifery, two WHO headquarters staff, 12 or more WHO staff and a number of special guests), lack of resources and little support. Table 1. Rationale for rankings Structure WHO Secretariat RANKING NOT WELL/SOMEWHAT WELL GAGNM is too large; too many people. Works in a silo leading to WHO general view that discounts GAGNM relevance and value. Not enough resources, staff or opportunities to meet. Not able to respond in a timely fashion. Shift to a teleconference format was disastrous. Insufficient in-depth analysis. RANKING WELL/VERY WELL 17

20 RANKING NOT WELL/SOMEWHAT WELL WHO recognition Not enough support from headquarters both administrative and political. Recommendations appeared to be given little weight; nursing and midwifery held in low esteem in WHO and not recognized as having value so proposals and recommendations not taken very seriously. RANKING WELL/VERY WELL Ensures contextualized nursing and midwifery policy advice to the Director- General and WHO Cabinet Provides guidance for future directions at regional and national level. Mechanism to strengthen nursing and midwifery political status at WHO and within its Member States. GAGNM leadership Purpose not well communicated. Meetings were poorly chaired. Agenda setting could have been improved to reduce time spent on talking sessions in favour of formulating recommendations about key issues. The majority of the meetings devoted to updates provided by WHO. So much depends on the capability and commitment of the Chair/Vice-Chair/ members and WHO. There was a lack of direction and true leadership within GAGNM. Platform for experts to clarify how and why nursing and midwifery input can facilitate/ assure achievement of objectives of WHO priority programmes. Global issues concerning nursing and midwifery are discussed. Gives visibility to the importance of nursing and midwifery. Important to select high calibre members for initial GAGNM known nurses and midwives; dedicated members who follow up. THE GAGNM S PERCEIVED BENEFITS Key informants clearly saw the value of the GAGNM with only one of 24 stating otherwise. As Table 2 demonstrates, benefits were largely seen as relating to WHO and global recognition/ visibility, having a policy voice (an ongoing concern from the beginning), advocacy for strengthening nursing and midwifery, opportunities to network with influential individuals, to be up to date on global issues and WHO priorities and actions, and the opportunity to help craft WHO products. 18

21 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW Table 2. Perceived major benefits of the GAGNM A platform for assuring nursing and midwifery voice/input at the highest level of WHO; An opportunity to understand the issues/challenges faced by nursing and midwifery professionals in different countries and to inform strategic plans and implementation; Recognition of nursing and midwifery within WHO and globally and among the professions; Bringing together multiple disciplines and several parties the global nursing and midwifery leadership as well as policy-makers, academics, researchers and international nursing organizations and increasing opportunities to learn from each other and to collaborate/network; Sustain the level of global commitment on and support of nursing and midwifery; Advocacy, solidarity, political will; Updates about WHO trends and priorities; Participation of GAGNM members in the development of documents (e.g. Strategic Directions on Nursing and Midwifery); Mobilize networks and high-level partners to advocate on strengthening nursing at country and regional levels; Provide policy directions to the WHO Secretariat; Built some external champions; and Encourage better understanding of how WHO works and the challenges faced by the WHO Secretariat. WHAT WOULD HAVE CHANGED THE RANKING AND WHAT SHOULD CHANGE TO IMPROVE EFFICIENCY AND EFFECTIVENESS? These questions, asked at different points in the interview, elicited responses that relate to two main areas: WHO support and resources to ensure GAGNM s efficient effectiveness; and the ways the GAGNM did its work. The responses are largely in line with remarks from the document review. As one respondent put it: GAGNM HAS BEEN OFTEN REMARKABLE IN ITS ABILITY TO CONTINUE TO MAKE POSITIVE CONTRIBUTION... The GAGNM needs enough of the right information to ask questions and make thoughtful suggestions and they need to know if their input has been useful. Volunteers become frustrated when asked to do something for which they do not have enough information and sense of fit. The suggestions below require not only adding resources, but adding the right ones. Using subgroups and working remotely can reduce staff time and increase the quality of materials produced. 19

22 Table 3. Changes necessary WHAT MIGHT HAVE CHANGED THE RANKING Resources/WHO support GAGNM should know in advance the issues in each programme and what expertise GAGNM could offer. More structured briefs and guiding notes for Chair/Vice-Chair. Improve WHO requests to GAGNM. Need money and mechanisms to communicate between meetings though easier now with IT. Stronger staffing of nurse/midwife capacity to follow up the ideas and discussions of the meetings between meetings. WHO chooses by geography and often does not get expertise. Should have a WHO pool of experts (nursing and midwifery and others) to draw on. A smaller more strategic group with a greater understanding of the political environment in which the GAGNM operates. Members of the group should be those who are aware of the key global issues affecting nursing and midwifery. Need support within WHO to bring GAGNM issues to the Director-General The Director-General could ask for a work plan from staff based on recommendations and reporting processes to the Director-General and Cabinet as well as GAGNM. Relevant WHO divisions should be expected to work in collaboration with nursing and midwifery to advance the recommendations approved by the WHO Director-General. More formal orientation of new members of GAGNM. WHAT TO CHANGE Resources/WHO support Need Secretariat and staff to guide GAGNM. Governments need to own nursing and midwifery. Strengthening the regional nurse/midwife advisory activity within WHO. GAGNM needs resources/visibility to achieve its TOR. Could use a small subgroup working on two or three priorities to try to get work done. Seek support of Assistant Director-General to support GAGNM. Composition of GAGNM increase diversity though not all can be engaged at the level they could be a performance management issue. Current mix OK if the non-nurses step up to the plate, but avoid diluting nursing and midwifery. WHAT MIGHT HAVE CHANGED THE RANKING Methods of working More in-depth analysis is required. Robust reports based on facts and the steps needed to strengthen the profession. Responding in a timely fashion. There should be at least six months lead in to looking at issues and evidence and what to recommend to facilitate presenting to the Director-General. More focus and rationale to presentations need to be more than information; less time for WHO updates, especially when speakers are not interested in the role of nurses and midwives in their work. Need to sustain tasks, follow-up timetables and products. Needs stronger chairs who understand WHO. Greater insight into priorities of Director-General at the time and a bit more time spent with him/ her on vision of stronger role of nursing and midwifery. Better chairmanship of teleconference meetings. Receipt of agenda papers much earlier with a structured approach to explore the issues. To engage with other sectors in WHO as nursing and midwifery affects everyone and cannot be separate. To engage more fully with the WHO Collaborating Centres network. More group time for development and finalization of recommendations to the Director-General. Structured working groups for follow-up and tactics. WHAT TO CHANGE Methods of working Need a more strategic focus; focus varies depending on communicators. Need to be sure GAGNM agenda reflects the broader WHO one as a framework for GAGNM planning. Select a very strong Chair and demonstrate successes to Director-General. Do work and generate results. WHO controls the agenda by devoting time to presentations rather than addressing critical issues. Have the meeting scheduled within a feasible timeline, because members have many commitments and it is not easy to find resources to attend it. Review past recommendations, pull out and see which are still relevant; how much has been accomplished; build a work plan/business case to move prioritized recommendations forward. Increase the kudos of being a member so as to leverage serious contributions. Case studies quite useful in increasing clarity with politicians rather than dry reports and use more vignettes people get it. 20

23 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW THE GAGNM OR AN ALTERNATIVE Key informants clearly believe the GAGNM is needed; only one of the 24 felt otherwise. It is needed to ensure policy input at the highest level as well as provide a global recognized mechanism to ensure nursing and midwifery services reflect changing health care contexts and represent the interests of Member States. In addition, it provides an accountability mechanism and it offsets the diminishing number of nursing and midwifery experts in WHO. It is an established vehicle and therefore has an advantage over something new. Restructured and resourced its work and weight could help maximize the nursing and midwifery contributions to health globally. Moreover, nurses and midwives are well fitted to address the chronic health care issues and environment of the current and coming decades. Table 4. The GAGNM or an alternative WHY THE GAGNM IS NEEDED Needed but also needs to be restructured; change the way it works, its agenda, etc. Needed to ensure a global/central recognized mechanism that continually defines/contextualizes nursing and midwifery services according to the changing global health needs and issues. The GAGNM is needed more than ever; however, it requires a stronger leadership and membership that sets specific goals to achieve its mission. Very important with current situation of WHO reform and absence of unit/team for nursing and midwifery. Also, it is important not to lose recognition built up over two decades. Needed but it could have a different title following WHO reforms. Lately, for example, reforms have increased calls for round table, expert meetings/ committees, high-level expert meetings, etc. Needed more than ever however, without a strong commitment to nursing and midwifery, the potential of the GAGNM will not be optimized. Without the GAGNM as an internal voice and resource, WHO will need to rely on interest groups whose agendas can complement but not replace that of the GAGNM as a representation of the interests of Member States. With the economic pressures in a constantly changing health environment it is important that a recognized forum is accessible for nursing and midwifery leaders and governments to provide advice and knowledge that can strengthen the use of human resources to improve the health of people worldwide. ALTERNATIVE Something new won t work. The GAGNM should be written into Member States undertakings. An alternative would only work if the body is part of the WHO system but not a line relationship. Collaborating Centres are not the answer which are good for regional nurses to have a network but not action oriented; they play a good assistance role. The GAGNM remains the best option; otherwise, consider regional nursing and midwifery advisory panels with a global panel that meets every two to three years to coordinate, review, analyse and form a global strategy based on regional groundwork. This would be welcomed even if the GAGNM remains: the regional panels would bring in diversity, challenges and provide best cases and illustrations for other regions to adapt. Need to sustain political commitment on nursing and midwifery which can feed inform WHO s operations, such as WHA resolutions, production of global guidelines etc. GAGNM could be transformed into several smaller expert groups that meet as required to analyse and give recommendations about the contribution of nursing services to specific health issues. Every region needs a small advisory or expert group to support WHO regional directors in a very intense and accountable way; there should be nursing and midwifery participation in every WHO regional committee. The problem is less structural than one of leadership, culture and commitment. The GAGNM should demonstrate leadership. 21

24 WHY THE GAGNM IS NEEDED Needs to continue or will lose benefits but needs to be accountable to WHO staff to evidence what it is doing for nursing and midwifery. The GAGNM is needed. It could be attached to the ICN/WHO/ICM meetings for Government Chief Nursing and Midwifery Officers, Presidents of Nursing and Midwifery Professional Associations and nursing and midwifery regulators (the triad sequence of meetings), which take place every second year and to a regional meeting every other year. This would help mobilize regional WHO activities as well as the WHO headquarters agenda. This would be more productive in accessing and prioritizing investment within the regional programmes. Should produce an annual report for the Executive Board and meeting reports and programmes every four months. Should also report to WHA every three years. Worldwide societies do not get the value they could from nurses and midwives and they are not maximized as most people do not understand or build conditions to facilitate this. GAGNM s working style needs change and it needs to be much more sensitive to the operating structure of WHO and make contribution to other WHO programmatic areas that have direct implications on nursing and midwifery. For many developing countries nurses and midwives continue to be the largest and main health workforce. The engagement of nursing advice and other professionals in the WHO Strategic Directions could still be a valuable exercise for the Director- General. Thus, the importance of an integrated strategic plan, development, monitoring, evaluating, etc. for nursing and midwifery continues to be important. There is very weak representation of nurses and midwives within WHO. The GAGNM should be smaller and more efficient in its working. The aims and objectives should be outcome based and its priority should be to support those working on behalf of nursing and nursing in WHO. The GAGNM should continue to advise the Director- General directly where possible to ensure constant awareness of nursing and midwifery issues and their contribution to the improvement of health. ALTERNATIVE A similar body is not likely to get approval and nursing and midwifery will decrease in importance. An interprofessional advisory group with representatives from nursing, medicine and key professional groups plus researchers and others to comment and provide direction from a health professional perspective. Retain the GAGNM along with support for both ICM and ICN policy advice and Regional Advisers for Nursing and Midwifery. The GAGNM is important to WHO. If there were to be an alternate structure or some changes to the current one the answer lies with the regions. Having regional nursing and midwifery advisory panels, with a global panel (GAGNM) that meets every two to three years to coordinate, review, analyse and form a global strategy based on regional groundwork would be welcomed. Even if the GAGNM remains the regional panels would bring in diversity, challenges and provide best cases and illustrations for other regions to adapt. KIs clearly saw the need for some smaller interdisciplinary groups and more support for regional nursing advisers. The majority see this happening within the context of the GAGNM: support for a renaissance is clear. 22

25 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW SUGGESTIONS FOR INCREASING THE CONTRIBUTION THE GAGNM MAKES Having confirmed the importance of the GAGNM and the inefficiencies in the system what remains is to put in place strategies to increase efficiency and effectiveness. With funding and other resources likely to remain tight, WHO could benefit by carefully selecting and fully preparing and supporting the championship and expertise of a global advisory group made up of highly respected leaders. Ten strategies to boost GAGNM s role Based on known theory and best practice, and responding to the input of 24 key informants, WHO should seriously consider the following ten strategies to make the GAGNM the world class advisory structure it is meant to be. Furthermore in the future, the work of the GAGNM should be oriented towards strengthening nursing and midwifery in the universal health coverage (UHC) agenda and the importance of having a well-balanced, motivated and competent health workforce which can ensure access to health services especially given that nurses and midwives constitute the largest group of health professionals in developing countries and they are the largest group of frontline professionals in countries in HRH crisis. 1. REACTIVATE THE GAGNM AS SOON AS POSSIBLE WITH A MIX OF OLD AND NEW MEMBERS Maintain a membership of not more than 12 and include a mix of members from a range of professions with the majority being nurses and midwives. The GAGNM should remain a technical advisory body on policy to the WHO Director-General and should adhere to the rules and regulations governing technical advisory bodies in WHO. WHO Regional Advisers for Nursing and Midwifery should continue to attend and fully participate in the meetings in addition to WHO Secretariat and other relevant staff. Furthermore, the four permanent observer organizations such as the ICM, ICN and ILO and the WHO Collaborating Centres Secretariat (maximum of one per organization) should also continue to participate fully. 2. AGREE AND USE MISSION, VISION AND VALUES TO GUIDE THE WORK AND INTERACTIONS The values or principles that guide GAGNM discussions and decision-making are very important, particularly where there is a constantly changing group. These tools are also helpful in addressing any conflicts that may arise. 3. ENLIST THE GAGNM IN REGULAR ENVIRONMENTAL SCANNING Given that the members are experts in their fields and geographically distributed, they should be an important asset for WHO in terms of identifying issues and trends. A consistent framework for scanning information collected can be tracked over time. Scanning should take place at least quarterly. This activity also keeps GAGNM members engaged and will be valuable to them as well as to WHO Regional Advisers for Nursing and Midwifery and permanent observers. 4. MAINTAIN ANNUAL INTERACTION WITH THE DIRECTOR-GENERAL AND SENIOR MANAGEMENT As in the TOR, GAGNM interaction with the WHO Director-General is important. This should take place after each GAGNM meeting. These meetings should be structured to advocate for nursing and midwifery issues. 23

26 5. WIDER DISSEMINATION OF THE GAGNM REPORT Wider dissemination of the GAGNM report and other relevant documents should be done to enable external and internal partners to understand the contribution the GAGNM makes to WHO. 6. DEVELOP INTERNAL POLICIES AND PROCEDURES TO SUPPORT THE GAGNM AND ASSIGN STAFF TO THESE Establish the GAGNM as an independent group which should develop its own operating procedures. Appointed members should nominate the Chair and Vice-Chair with WHO providing secretarial support. Among other things policy and procedures should address a routine list of documents to be prepared and circulated to GAGNM members in advance. Timing, format and content of these documents needs to be outlined, along with who in the GAGNM and WHO needs to be consulted. 7. MAINTAIN REGULAR COMMUNICATIONS WITH AND ABOUT THE GAGNM Communications with the GAGNM should be improved to include regularly scheduled meetings (face-to-face, video, Skype, etc.) as well as ad hoc ones. In addition to the annual meeting, quarterly teleconferences should be held and should be booked well in advance. The focal points for nursing and midwifery at headquarters and regional levels are encouraged to share with the GAGNM by or web a regular, short update of what is happening in WHO. 8. ENSURE THE CONTENT OF MEETINGS REFLECTS GAGNM S AGENDA AND REMIT The agenda for the GAGNM must be set with the Chair and needs to be balanced to reflect the important technical issues that require attention of WHO and partners in strengthening nursing and midwifery services. It is important that the group adheres to its TOR this includes resource mobilization. 9. ENSURE DOCUMENTATION FOR MEETINGS IS OUT WELL IN ADVANCE AND CONTAINS SOUND ANALYSIS AND CLEAR DIRECTIONS FOR ANY NEEDED ACTION There are currently many missing records of meetings due to staff change at WHO headquarters which makes transparency and follow-up, as well as future research, extremely difficult. Therefore, documentation and archiving of GAGNM meetings and reports and other related documents should be carried out with appropriate briefing to succeeding WHO staff on the importance of maintaining a full record. 10. GAGNM RECOMMENDATIONS AND EVALUATION The work of the GAGNM should remain to provide technical advice. It is the role of the Secretariat and partners to implement the recommendations of the GAGNM and self-evaluation of the GAGNM should be done when the group meets and reviews the extent to which recommendations have been implemented and if not the reasons why and advocate for their implementation. 24

27 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW CONCLUSION Nurses and midwives will continue to be the backbone of health care for decades to come. It is important that WHO and Member States have sound policy guidance to optimize nursing and midwifery contributions to the health of all nations. The GAGNM, properly supported and utilized, can be of enormous value to WHO both regionally and globally. However, as KIs put it: Any institution will remain as good as its membership and leadership; if either is weak, the output in all likelihood will be weak. (Key informant, 2013) The single most important question regarding the effectiveness of GAGNM is: What would have happened if it hadn t been there over these years? (Key informant, 2013) 25

28 REFERENCES ICN, years of collaboration. The International Council of Nurses and the World Health Organization: A growing and fruitful partnership. Geneva, ICN. Kennedy MS, The WHO s Global Advisory Group on Nursing and Midwifery Meets in Geneva. American Journal of Nursing, Vol. 109, Issue 6: 61 (doi: /01. NAJ f7). Thompson JE, The WHO Global Advisory Group on Nursing and Midwifery. Journal of Nursing Scholarship, 34:2, WHO, Public Health Nursing: Fourth Report of the Expert Committee on Nursing. Technical Report Series October Geneva, World Health Organization. WHO, WHO Expert Committee on Nursing: Fifth Report. Technical Report Series April 2 May. Geneva, World Health Organization. WHO, Resolution WHA45.5. Strengthening nursing and midwifery in support of strategies for health for all. Handbook of Resolutions. Vol. III (2nd ed.), 1.8 (Eleventh plenary meeting, 11 May Committee A, first report). WHO, Nursing Beyond the Year Report of a WHO Study Group. Technical Report Series, No 842. Geneva, World Health Organization. WHO, Strategic Directions for Strengthening Nursing and Midwifery Services. Geneva, World Health Organization. WHO, Report of the Stakeholders meeting on nursing and midwifery contributions to achieving the Millennium Development Goals for health, Geneva 2 3 May Geneva, World Health Organization ( accessed 10 September 2013). WHO, Progress reports. Report by the Secretariat Optimizing the contribution of nurses and midwives. Sixty-Third World Health Assembly, A63/27 Provisional agenda item April Geneva, World Health Organization. WHO, A Global Survey Monitoring, Progress in Nursing and Midwifery. Geneva, World Health Organization. The GAGNM meeting reports WHO, Report of the First Meeting of the GAGNM. Geneva 30 November 2 December. Geneva, World Health Organization. WHO, Report of the Second Meeting of the GAGNM. Geneva 8 10 November. Geneva, World Health Organization. WHO, Report of the Third Meeting of the GAGNM. Geneva November. Geneva, World Health Organization. WHO, Report of the Fourth Meeting of the GAGNM. Delhi December. Geneva, World Health Organization. WHO, Report of the Fifth Meeting of the GAGNM. Geneva 8 10 April. Geneva, World Health Organization. WHO, Report of the Sixth Meeting of the GAGNM. Geneva November. Geneva, World Health Organization. 26

29 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW WHO, Report of the Seventh Meeting of the GAGNM. Geneva November. Geneva, World Health Organization. WHO, Report of the Eighth Meeting of the GAGNM. Geneva 9 11 October. Geneva, World Health Organization. WHO, Report of the Ninth Meeting of the GAGNM. Geneva 3 4 May. Geneva, World Health Organization. WHO, Report of the Tenth Meeting of the GAGNM. Geneva February. Geneva, World Health Organization. WHO, Report of the Eleventh Meeting of the GAGNM. Geneva March. Geneva, World Health Organization. WHO, Report of the Twelfth Meeting of the GAGNM. Geneva March. Geneva, World Health Organization. WHO, Report of the Thirteenth Meeting of the GAGNM. Geneva March. Geneva, World Health Organization. 27

30 ANNEX A: WHA45.5 STRENGTHENING NURSING AND MIDWIFERY IN SUPPORT OF STRATEGIES FOR HEALTH FOR ALL The Forty-fifth World Health Assembly, Having considered the Director-General s report on strengthening nursing and midwifery in support of strategies for health for all, and the discussions at the eighty-ninth session of the Executive Board; Recalling resolution WHA42.27; Mindful of the growing demand for and cost of health care in countries throughout the world; Concerned at the continued shortage of nursing and midwifery personnel and the urgent need to recruit, retain, educate, and motivate sufficient numbers to meet present and future community health needs; Recognizing the need to increase the Organization s nursing and midwifery activities at all levels; Committed to the promotion of nursing and midwifery as essential health services in all countries, for the development and improvement of health-for-all strategies; 1. THANKS the Director-General for his report; 2. URGES Member States: (1) to identify their nursing and midwifery service needs and, in this context, assess the roles and utilization of nursing and midwifery personnel; (2) to strengthen managerial and leadership capabilities and reinforce the positions of nursing and midwifery personnel in all health care settings and at all levels of service, including the central and local services of health ministries and the local authorities responsible for the programmes concerned; (3) to enact legislation, where necessary, or take other appropriate measures to ensure good nursing and midwifery services; (4) to strengthen education in nursing and midwifery, adapt educational programmes to the strategy for health for all, and revise them where appropriate, in order to meet the changing health care needs of populations; (5) to promote and support health services research that will ensure the optimal contribution of nursing and midwifery to health care delivery, with particular emphasis on primary health care; (6) to ensure appropriate working conditions in order to sustain the motivation of personnel and improve the quality of services; (7) to ensure the allocation of adequate resources (financial, human and logistic) for nursing and midwifery activities; (8) to ensure that the contribution of nursing and midwifery is reflected in health policies; 28

31 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW 3. REQUESTS WHO regional committees to reinforce regional actions in order to enable Member States to implement the above provisions effectively and to identify sources for financing such actions in those States which are undergoing economic structural reform programmes or which have other special needs; 4. REQUESTS the Director-General: (1) to establish a global multidisciplinary advisory group on nursing and midwifery, with the express purpose of advising the Director-General on all nursing and midwifery services, and in particular on: (a) developing mechanisms for assessing national nursing and midwifery service needs; (b) assisting countries with the development of national action plans for nursing and midwifery services including research and resource planning; (c) monitoring progress in strengthening nursing and midwifery in support of strategies for health for all; (2) to mobilize the increased technical and financial support required to implement the provisions of this resolution; (3) to ensure that the interests of nursing and midwifery services are taken into account in policy implementation and programme development, and that nursing and midwifery experts participate in WHO committees as appropriate; (4) to strengthen the global network of WHO collaborating centres for nursing and midwifery with a view to the implementation of health for all; (5) to report on progress made in the implementation of this resolution to the Forty ninth World Health Assembly. Handbook of Resolutions. Vol. III (2nd ed.), 1.8 (Eleventh plenary meeting, 11 May Committee A, first report). World Health Assembly, Fifty-fourth World Health Assembly (WHA54.12): Strengthening nursing and midwifery. Geneva: World Health Organization (WHA54/2001/REC/3). World Health Assembly, Fifty-ninth World Health Assembly (WHA59.27): Strengthening nursing and midwifery. Geneva: World Health Organization. 29

32 ANNEX B: KEY INFORMANTS IN THE REVIEW PROCESS Naeema Al-Gaseer WHO Representative Office Egypt World Health Organization P.O. Box 11516, Cairo Tel: / / Fax: wregypt@egy.emro.who.int Former Chief NM Scientist Isabel Amélia Costa Mendes Secretary General Global Network of WHO Collaborating Centres for Nursing and Midwifery Development Avenida Bandeirantes, 3900 Campus Universitário Ribeirão Preto, SP CEP Brazil Tel: Mobile: iamendes@usp.br GAGNM observer Miriam Hirschfeld Professor and Head of Nursing Department HaRav Herzog Street 22/20 Tel Aviv Israel Tel/Fax: mj.hirschfeld@gmail.com Former WHO Chief NM Scientist Former Director, HRH, WHO HQ Nabil Kronfol Professor of Health Policy and Management Clemenceau Street, Clemenceau 333 Building, Beirut, Lebanon Tel: Mobile: dino@cyberia.net.lb nabilkronfol@yahoo.co.uk Current GAGNM member David Benton Chief Executive Officer International Council of Nurses 3 Place Jean Marteau CH 1201 Geneva Tel: benton@icn.ch GAGNM Observer Ainna Faucett-Henesy Daeville Summerville Avenue South Circular Road Limerick, Ireland Tel: Mobile: ainna@eircom.net Former RNA, WHO EURO Constance Holleran 3567 S. Leisure World Boulevard Silver Spring MD Tel: hollerac@aol.com Former Executive Director ICN, GAGNM observer T Dileep Kumar President Indian Nursing Council Combined Council Building Kotla Road, Temple Lane New Delhi, India Tel: Mobile: tdileep55@gmail.com Current GAGNM member Eric Chan Principal Nursing Officer Hong Kong Hospital Authority China, Hong Kong Special Administrative Region Tel: chanels@ha.org.hk GAGNM Vice-Chair Kathlyn Fritsch Regional Adviser, Nursing WHO Western Pacific P.O. Box 2932, United Nations Avenue 1000 Manila, The Philippines Tel: Fax: Mobile: FRITSCHK@wpro.who.int Current RNA, WHO WPRO Petra ten Hoope-Bender Director RMNCH ICS Integrare c. Diputació, , Barcelona, Spain Tel: Mobile: petra.tenhoope@integrare. es Former ICM Chief Executive Officer and GAGNM observer Sandra MacDonald-Rencz Nursing Executive, Strategic Policy Branch, Room B1835, 200 Promenade Eglantine Driveway, PL 1905B Tunney s Pasture, Ottawa ON K1A 0K9 Tel: Mobile: sandra.macdonaldrencz@hc-sc.gc.ca GCNMO and GAGNM observer 30

33 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW Silvina Malvárez Advisoer, Nursing and Health Technicians Technical Adviser of PALTEX Coordinator of the virtual program in Health and Local Development Primary health Care based Health Systems Area PAHO/WHO rd Str Washington, DC - #623 Tel: malvares@paho.org Current RNA, WHO AMRO Galina Perfilieva Programme Manager HRH Programme Division of Health Systems and Public Health WHO Regional Office for Europe 8 Scherfigsvej, 2100 Copenhagen Denmark Tel: Mobile: gpe@euro.who.int Former observer, WHO EURO staff Judith Shamian President Emeritus VON Canada 88 Rockford Road Toronto M2R 3A7 Tel: Mobile: shamianjudith@gmail.com Former GCNMO and GAGNM observer Viroj Tangcharoensathien Senior Expert on Health Economics, Adviser to IHPP IHPP, Ministry of Public Health, Nonthaburi, Thailand viroj@ihpp.thaigov.net Current GAGNM member Maricel Manfredi Kings Crossing Blvd, Boyds MD Tel: Mobile: maricelmanfredi@aol.com Current GAGNM member; Former Regional Adviser in Human Resources in Nursing, WHO AMRO Margaret Phiri Regional Nursing Adviser WHO AFRO phirim@bf.afro.who.int Current RNA, WHO AFRO Kirsten Stalknecht Past President International Council of Nurses Tunet 31, 3450 Alleroed Denmark Tel: stallknecht@privat.dk Former ICN President and GAGNM member Joyce E Thompson Independent International Consultant in Midwifery, Women s Health, Ethics Enzian Road, Delton, MI Tel: Mobile: joycethompsonllc@gmail. com Former GAGNM Vice-Chair and member Barbara Parfitt Professor/Director Global Health Development and Principal Grameen 11A Kirkintilloch Road, Lenzie, Glasgow, G66 4RW, UK/ Caledonian College of Nursing Bangladesh Tel: Mobile: b.a.parfitt@gcu.ac.uk Former Secretary General Global Network of WHO Collaborating Centres for Nursing and Midwifery Development and GAGNM observer Marla Salmon Professor, Nursing and Public Health Global Health, University of Washington 209G Parrington Hall Box , Seattle, WA Tel: Mobile: msalmon@uw.edu Former GAGNM Chair Pelenatete Stowers ACEO Health Services Performance and Quality Assurance: Nursing and Midwifery Tel: Fax: PelenateteS@health.gov.ws Current GAGNM member Lis Wagner Professor, Nursing Research Faculty of Health Sciences University of Southern Denmark Farvergaardsvej 24, 3210 Vejby, Denmark Mobile: lwagner@health.sdu.dk GAGNM member Former Regional Adviser Nursing and Midwifery WHO EURO 31

34 ANNEX C: WHO GAGNM INTERVIEW GUIDE Purpose: Review and provide recommendations on strengthening the Technical Expert Panel and Global Advisory Group for Nursing and Midwifery (GAGNM); in particular to determine optimal ways to improve their utility and effectiveness. All information will be collated with none attributed to any individual. DEMOGRAPHIC INFORMATION Name: Job title: Address: Tel: Mobile: Position vis à vis GAGNM: Dates: Average number of meetings attended: INTERVIEW CONTENT INFORMATION The GAGNM was created in 1992 as a strategic, action-oriented body providing policy advice to the Director-General and the WHO Cabinet to strategically enhance the contributions of nursing and midwifery within the context of all WHO priorities and programmes. HOW WELL HAS GAGNM LIVED UP TO ITS PURPOSE ON A SCALE OF 1 TO 4? (1 not well; 2 somewhat well; 3 well; 4 very well) TO WHAT DO YOU ATTRIBUTE YOUR RATING? IF THE RATING IS LESS THAN 4, WHAT MIGHT HAVE BEEN DONE TO ELEVATE THE RATING? 32

35 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW THE GAGNM HAS FIVE DISTINCT TERMS OF REFERENCE. PLEASE RATE THESE ON THE FOLLOWING SCALE. (1 not important/not achieved; 2 somewhat important/somewhat achieved; 3 important/achieved; 4 highly important/highly achieved) For each element please tick one column for importance and one for achievement. TERMS OF REFERENCE IMPORTANCE ACHIEVEMENT To guide the development of the global agenda for nursing and midwifery within the overall health agenda. To provide policy advice on how the responsiveness of health systems to people s health needs can be optimized through the effective use of nursing and midwifery services that are based on research as scientific evidence. To support the development and use of nursing and midwifery outcome indicators in relation to health gains and health status. To participate in resource mobilization and efforts for the effective implementation of the global agenda for nursing and midwifery. To collaborate in establishing mechanisms for monitoring the progress of nursing and midwifery contributions to the health agenda and to the implementation of the global agenda for nursing and midwifery. WHAT HAVE BEEN THE MAJOR BENEFITS OF THE GAGNM? IS THE GAGNM OR A SIMILAR STRUCTURE NEEDED TODAY? WHY/WHY NOT? IF NOT NEEDED, WHAT ALTERNATIVE WOULD YOU RECOMMEND FOR PROVIDING NURSING/ MIDWIFERY POLICY ADVICE TO THE DIRECTOR-GENERAL AND THE WHO CABINET? 33

36 WHAT WOULD YOU CHANGE (AND HOW) THAT WOULD ENSURE THE GAGNM/NEW VEHICLE IS MORE EFFECTIVE THAN AT PRESENT? OTHER COMMENTS/ RECOMMENDATIONS THANK YOU 34

37 GLOBAL ADVISORY GROUP ON NURSING AND MIDWIFERY: 2013 REVIEW ANNEX D: DEVELOPMENT OF GAGNM TERMS OF REFERENCE * 2010 Guide the development of the global agenda for nursing and midwifery within the health agenda. Provide policy advice on how the responsiveness of health systems to peoples health needs can be optimized through the effective use of nursing and midwifery services, which are based on research as scientific evidence. Support the development and use of nursing and midwifery outcome indicators in relation to health gains and health status. Participate in resource mobilization and efforts for the effective implementation of the global agenda for nursing and midwifery. Collaborate in establishing mechanisms for monitoring the progress of nursing and midwifery contributions to the health agenda and to the implementation of the global agenda for nursing and midwifery. * Developed by a steering committee, Advise the DG and through the DG the regional directors in response to Resolutions 45.5 and WHA 49.1 on strengthening nursing and midwifery, in particular: Analyse and assess the impact of current and anticipated socioeconomic, political, demographic and epidemiological trends on nursing and midwifery, within the context of the Health for All (HFA) renewal strategy Within this context provide advice to WHO on how its work toward HFA at all levels can be optimized through the effective work of nursing and midwifery. Guide WHO on the monitoring of progress on nursing and midwifery development and the implementation of WHA Resolution Advise the DG on nursing and midwifery, as an important resource for improving the health of all people, increasing equity of health outcomes, and ensuring the right of all people to health care. Guide the development of the global agenda for nursing and midwifery, within the health agenda. Provide policy advice on how the responsiveness of health systems to peoples health needs can be optimized through the effective use of nursing and midwifery services which are based on research as scientific evidence. Support the development and use of nursing and midwifery outcome indicators in relation to health gains and health status. Participate in resource mobilization and efforts for the effective implementation of the global agenda for nursing and midwifery. Collaborate in establishing mechanisms for monitoring the progress of nursing and midwifery contributions to the health agenda and to the implementation of the global agenda for nursing and midwifery. Advise the DG on strengthening the nursing and midwifery, contributions to global health and what is needed to make such contributions possible. Provide policy advice to the DG on how nursing and midwifery services can optimize the responsiveness of health systems to people s needs. Supporting the development and use of nursing and midwifery outcome indicators globally. Advise on long-term strategic plans for nursing and midwifery within WHO. Collaborate in monitoring progress of nursing and midwifery contributions to the health agenda, particularly WHO s programmes and priorities. 35

38 Notes 36

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