By Charlotte Houde Quimby, RNP/CMW
and Mary Lee Mantz, RNP/CMW
January 2000
Expanding Access
 to Reproductive Health
 Through Midwives
Family Planning Service Expansion
and Technical Support
Lessons Learned From SEATS’ MAPS Initiative
The goal of the Family Planning Service Expansion and Technical Support
(SEATS) Project is to expand access to and use of high-quality, sustain￾able family planning and reproductive health services.
John Snow, Inc. (JSI), an international public health management consult￾ing firm, heads a group of organizations implementing the SEATS Project.
These include the American College of Nurse-Midwives (ACNM), AVSC
International, Initiatives, Inc., the Program for Appropriate Technology in
Health (PATH), World Education, and partner organizations in each
country where SEATS is active.
This publication was made possible through support provided by the
Office of Population, United States Agency for International Develop￾ment (USAID) under the terms of Contract No. CCP-C-00-94-00004-10,
and by John Snow, Inc. (JSI). The contents and opinions expressed
herein are those of the authors and do not necessarily reflect the views
of USAID or JSI.
By Charlotte Houde Quimby, RNP/CMW
and Mary Lee Mantz, RNP/CMW
January 2000
Expanding Access
 to Reproductive Health
 Through Midwives
Lessons Learned From SEATS’ MAPS Initiative
Family Planning Service Expansion
and Technical Support
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Dedication
The Midwifery Association Partnerships for Sustainability (MAPS)
Special Initiative is dedicated to the late Bonnie Pederson, who, in
addition to her many accomplishments, was also and always a
midwife. Bonnie believed that midwives could make a difference
in improving the lives of women and children throughout the
world, and she dedicated her life and her career to assisting mid￾wives to fulfill their potential as family planning/reproductive health
service providers. She provided guidance in the initial develop￾ment of MAPS and enthusiastic support during the project’s
implementation.
Bonnie is an inspiration to all midwives everywhere. We think she
would be proud of the accomplishments of MAPS.
i

SEATS’
lessons learned from
MAPS I n i t i a t i v e
iii
Acknowledgements
The Midwifery Association Partnerships for Sustainability (MAPS)
Initiative is about midwives, their professional associations, and their
tireless efforts to improve reproductive health care for families through￾out Africa and the world. The success of the MAPS Initiative is mainly
a result of the dedication of these men and women. In particular, the
authors would like to thank the following professional organizations
and leaders:
Zimbabwe Nurses Association (ZINA) and Mrs. Clara Nondo, former
ZINA President; Zambia Nurses Association (ZNA) and Mrs. Olive
Nganda, ZNA President; Uganda Private Midwives Association
(UPMA) and Mrs. Mary Musoke Goretti, former UPMA President and
Theresa Nantale, UPMA President; Independent Clinics Organization
(ICO) and Veronica Zimunhu, ICO acting Chairperson; Association of
Senegalese Midwives (ANSFS) and Mrs. Marianne Ndiaye, ANSFS President.
MAPS was indeed fortunate to have project coordinators who man￾aged the MAPS subprojects and provided invaluable guidance during
implementation. A special thanks and a “job well done” to Mrs. Tina
Nduna (Zimbabwe), Mrs. Fanny Chikamba and Mrs. Anna Chirwa
(Zambia), Mrs. Mary Kiwalabye (Uganda), and Mrs. Aida Lo and Mrs.
Diop (Senegal).
We would like to acknowledge the special efforts of the SEATS Project
and ACNM administration and staff who provided technical assistance,
direction, and support to MAPS. These include, but are not limited to:
Dr. Frank Webb, Dr. Laurel Cappa, Ms. Joy Awori, Ms. Deanne Will￾iams, Ms. Deborah Armbruster, Ms. Donna Vivio, Ms. Irene Mugizi,
Mr. Paul Mudzongo, Dr. William Muhwava, Mr. Timothy Williams, Ms.
Asta-Maria Kenney, Ms. Shalote Chipamaunga, Ms. Vielly Bafana, Ms.
Leslie Patykewich, Ms. Sarah Bolton, Ms. Lisa Mueller, Ms. Joan Haffey,
Ms. Willow Gerber, Mr. Roy Brunson, Ms. Joy Benn, Ms. Diane
Hedgecock, and Ms. Elaine Rossi. Thanks also goes out to Mr. Drew
Banks for document design and layout and Ms. Sue Carrington for
editorial assistance.
SEATS’
lessons learned from
MAPS I n i t i a t i v e iv
Ms. Frances Ganges, MAPS Resident Advisor in Uganda, has been
instrumental in the development, design, and implementation of
MAPS. Her wisdom, expertise, dedication, and sensitivity have contrib￾uted so much to the success of MAPS.
A special thank you to Dr. Rose Ndlovu, Chairperson of the University
of Zimbabwe Department of Nursing Sciences and President of the
East, Central, and Southern African College of Nursing (ECSACON);
Mr. Peter Cowley, Country Director Commercial Market Strategies
(CMS) Project Uganda; Jay Anderson, former Health, Population, and
Nutrition Officer, USAID/Uganda; and Mrs. Tembi Matatu, Delivery of
Improved Services for Health (DISH) Project Training Advisor, Uganda; all of
whom gave generously of their expertise and support in assisting MAPS.
We also would like to acknowledge the strong backing of the USAID
missions in Uganda, Zambia, and Zimbabwe.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
List of Acronyms
v
ACNM The American College of Nurse-Midwives
AIDS Acquired immune deficiency syndrome
ANSFS Association Nationale des Sage-Femmes Sénégalaises
(Association of Senegalese Midwives)
CE Continuing education
CMA Cambodian Midwives Association
CMS Commercial Market Strategies Project
CQI Continuous quality improvement
CYP Couple-years of protection
DISH Delivery of Improved Services for Health
ECSACON East, Central, and Southern African College of Nursing
FP Family planning
HIV Human immunodeficiency virus
HPC Health Professions Council
ICM International Confederation of Midwives
ICO Independent Clinics Organization
IEC Information, education, and communication
JSI John Snow, Inc.
LAM Lactational amenorrhea method
LSS Life-saving skills
MAPS Midwifery Association Partnerships for Sustainability
MIS Management information systems
MOH Ministry of Health
NAMAS National Medical Aid Societies
NGO Nongovernmental organization
PMW Private midwife
PROFIT Promoting Financial Investments and Transfers Project
SEATS’
lessons learned from
MAPS I n i t i a t i v e vi
PSI Population Services International
PSMAS Public Service Medical Aid Society
PVO Private voluntary organization
RHC Reproductive health care
SDP Service delivery point
SEATS Family Planning Service Expansion and
Technical Support
SOMARC Social Marketing for Change Project
STI Sexually transmitted infection
TA Technical assistance
TAMA Tanzanian Midwives Association
TFR Total fertility rate
TOT Training of trainers
UNFPA United Nations Population Fund
UPMA Uganda Private Midwives Association
USAID United States Agency for International Development
WHO World Health Organization
YFS Youth-friendly services
YFT Youth-friendly training
ZAPSO Zimbabwe AIDS Prevention and
Support Organization
ZINA Zimbabwe Nurses Association
ZMG Zimbabwe Midwives Group
ZNA Zambia Nurses Association
ZNFPC Zimbabwe National Family Planning Council
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MAPS I n i t i a t i v e
vii
Table of Contents
ACKNOWLEDGEMENTS ........................................................................ iii
ACRONYM LIST ........................................................................................ v
EXECUTIVE SUMMARY........................................................................... ix
INTRODUCTION ......................................................................................1
The SEATS II Project...................................................................................2
The MAPS Initiative ...................................................................................3
Publication Overview................................................................................5
MAPS APPROACH....................................................................................7
Three Levels of Association Development .............................................8
Zimbabwe: An Illustrative Example .........................................................9
MAPS STRATEGIES..................................................................................13
I. Capacity Building of Associations ....................................................13
Case Study: Coalition Building through a Study Tour .............. 15
II. Capacity Building for Members........................................................17
Case Study: Serving Youth in Zambia ....................................... 21
III. Creatiomn of a More Enabling Environment ................................. 22
IV. Integration of Quality and Sustainability ........................................ 23
Quality................................................................................................. 23
Case Study: Developing a Model Clinic in Uganda ................ 27
Sustainability....................................................................................... 28
Case Study: MAPS/ICO Sustainability Plan ...............................31
V. Policy Initiatives.................................................................................. 34
LESSONS LEARNED............................................................................... 37
THE FUTURE OF MAPS......................................................................... 43
REFERENCES ........................................................................................... 47
SEATS’
lessons learned from
MAPS I n i t i a t i v e SEATS’
lessons learned from
MAPS I n i t i a t i v e viii
APPENDICES
1. MAPS Country Project Summaries
2. Special Study Recommendations
3. Uganda Study Tour Action Plan
4. Criteria for Selection of Model Clinics
5. Article on UPMA Clinic Opening
6. ICO Sustainability Action Plan
SEATS’
lessons learned from
MAPS I n i t i a t i v e
ix
Executive Summary
Population growth is one of the world’s most pressing concerns. In the
next 25 years, the world’s population is projected to increase to nearly
eight billion people. The most growth is expected to occur in Africa,
Asia, and Latin America—regions with the least resources. If these
predictions are accurate, the majority of the people in the world will be
affected by reductions in quality of life, in life expectancy, and in
environmental and economic stability.
While no simple solution to the global population crisis is likely to be
found, associated problems can be successfully addressed. One key
problem is lack of access to contraceptives and high-quality reproduc￾tive health care services. Providing this access could prevent some of
the millions of unwanted pregnancies that occur each year and save
the lives of millions of mothers and children. High-quality reproductive
health programs are needed that are sustainable, appropriate to local
cultures, and sensitive to client needs.
One program that seeks to increase access to family planning (FP) and
reproductive health care (RHC) is the Midwifery Association Partner￾ships for Sustainability (MAPS). MAPS is a Special Initiative of the
Family Planning Service Expansion and Technical Support Project
(SEATS II)—funded by the United States Agency for International
Development (USAID) and implemented by John Snow, Inc. (JSI) in
collaboration with its partners. SEATS’ partner, the American College of
Nurse-Midwives (ACNM), implements MAPS.
The MAPS Initiative promotes the development of midwives as a way
to address unmet needs for FP/RHC. MAPS works with midwives in
the private and public sectors, through their professional associations.
This focus on associations helps to strengthen and maintain high
standards and expand services. Activities that support the develop￾ment of private midwife practices ensure access to high-quality ser￾vices for clients. MAPS uses a variety of activities—such as training,
advocacy, and policy changes—to ensure that midwives can reach their
full potential as a community-based resource.
SEATS’
lessons learned from
MAPS I n i t i a t i v e x
MAPS began its efforts in 1995. Since then, the program has created
and implemented projects in four countries in Africa—Senegal,
Uganda, Zambia, and Zimbabwe—and assisted midwifery associations
in Cambodia, Eritrea, and Tanzania. MAPS has increased access to FP
and RHC services by:
ª Providing services in communities where public-sector ser￾vices are limited or unavailable (e.g., rural areas).
ª Integrating family planning into existing reproductive health
care services.
ª Reducing practice barriers.
ª Providing health care alternatives for clients.
MAPS strategies include:
ª Capacity building of associations.
ª Capacity building of members.
ª Creation of more enabling practice environments.
ª Promotion of quality and sustainability.
ª Creation of model clinics.
ª Development of policy initiatives.
These strategies were implemented differently in each country where
MAPS worked. Each subproject had a somewhat different focus
depending on the situation. MAPS offered flexibility and a wide range
of family planning and reproductive health training and association
development capabilities to fit specific country needs—a customized
approach that proved highly successful.
Sustainability is also a major goal of MAPS. Building the sustainability
of an association means building the capacity for self-governance,
management, training, advocacy, diversification of funding sources,
strategic planning, and marketing. It addresses reducing barriers that
prevent private midwives (PMWs) from offering a full range of services,
including family planning. To support sustainability of individual
midwives, MAPS focuses on improving quality of care, strengthening
the marketing capability of PMWs, increasing access to family planning
care, and introducing user fees. The project facilitated outreach
activities by the PMWs to make communities more aware of their
services. In reaching beyond their clinics to the communities they
served, midwives learned a great deal about community needs, per￾ceptions of care, and barriers to access.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
xi
The MAPS Initiative includes a strong training program to expand
midwives’ knowledge, skills, and attitudes. Training covered areas such
as mobilizing communities, managing a business, keeping records of
service statistics, and monitoring quality of care. During the MAPS
end-of-project evaluations, midwives reported that these activities
contributed greatly to their professional growth.
Despite the short-term nature of most of the subprojects, MAPS
accomplished many objectives. The initiative strengthened the capac￾ity of associations and the skills of midwives; it helped position private￾practice midwives as change agents; and it helped midwives increase
client access to and use of effective contraception.
During the course of the project, MAPS learned many valuable
lessons, including:
1. The power of quality can never be underestimated.
2. Flexibility and perseverance are needed to operate within the
constraints of a situation or country.
3. Every new situation should be treated as a teaching and
learning opportunity, with mid-course adjustments made, and
midwives consulted for creative problem solving.
4. Barriers to private practice severely limit the potential contri￾bution of midwives to reducing the unmet need for RHC
services.
5. RHC service delivery points are incomplete without minor
curative services and immunization capability.
6. In unity, there is strength.
7. The human immunodeficiency virus/acquired immune defi￾ciency syndrome (HIV/AIDS) has permanently changed the
service delivery environment.
8. Basic business management skills and community mobiliza￾tion skills are critical to the viability of private midwives.
9. Monitoring and long-term supervision of midwives on a
sustained basis is difficult.
10. Learning how to monitor quality takes time.
11. Private midwives serve existing needs and reduce the public￾sector burden.
12. Private practice expands service.
SEATS’
lessons learned from
MAPS I n i t i a t i v e xii
The MAPS experience illustrates that, with adequate support, midwives
can successfully expand access to reproductive health care. They can
reach underserved populations and provide high-quality, integrated
reproductive health services, including family planning.
In future efforts, MAPS will concentrate on consolidating its achieve￾ments while continuing to build on its strengths. Two special areas that
would benefit from continued focus are: 1) strengthening community
mobilization and links with nongovernmental organizations (NGOs)
and 2) empowering midwives by removing barriers to practice. These
activities will continue to expand the role of midwives as a valuable
community resource.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
1
Around the world: Around the world:
ª 300 million couples use
unsatisfactory or unreliable
contraceptive methods.
ª 30 million unintended
pregnancies occur each
year in women using
contraception.
ª At least 150 million couples
do not have access to family
planning.
U.S. Bureau of the Census, 1999
Introduction
The world’s population is expected to increase to nearly eight billion
people within the next 25 years (U.S. Bureau of the Census 1999).
Ninety-five percent of this growth will occur in the developing regions
of Africa, Asia, and Latin America—the world’s economically poorest
regions with the fewest resources for providing health care, housing,
sanitation, education, and employment. The burdens of such popula￾tion demographics have profound and far-reaching consequences on
the quality of life, life expectancy, environmental needs, and economic
stability of the majority of the world’s people:
ª In 1998, more than seven million infants throughout the world
died before their first birthday. More than 11 million children
died before celebrating their fifth birthday. Less than one
percent of these deaths occur in the more developed coun￾tries. Factors found to be most closely associated with child￾hood mortality are short intervals between births and minimal
maternal education (U.S. Bureau of the Census 1999).
ª Maternal mortality is a major health problem, particularly in
less-developed countries. A woman in sub-Saharan Africa has
a lifetime chance of 1 in 48 of dying in childbirth compared to
a 1 in1,800 chance in developed countries. The fact that the
great majority of maternal deaths are preventable adds to the
magnitude of this tragedy (Marshall and Buffington 1998).
Midwives are a key part of solving the crisis of unmet
need in family planning and reproductive health care.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 2
Family planning (FP) and reproductive health care (RHC) are key to
solving this global pressing need. FP saves women’s and children’s
lives and is a central component of quality RHC services. The single
most important determinant of future fertility is the extent to which
couples have access to and use contraception to control the number
and spacing of their children.
The need for quality FP services remains unmet. The reasons for this
deficiency are many and varied. They include technology issues,
barriers to access or to service delivery, and poor quality of services.
Social issues—such as the role of women in society, attitudes towards
birth control and sex, and national health priorities—also contribute
significantly.
The HIV/AIDS pandemic further affects the reproductive health of
women and men. HIV and other sexually transmitted infections (STIs)
have an enormous negative impact on those they affect, typically when
they are at their peak reproductive age.
No single approach can address these problems. Rather, a variety of
responses are required that are sustainable, adaptable to the local
culture, and sensitive to the complexity of client needs. Models of care
are needed that provide high-quality services while addressing client
needs for safe sex and for contraception. Also necessary are programs
that serve a wide spectrum of population groups, including the
underserved.
The SEATS II Project
The Family Planning Service Expansion and Technical Support Project
(SEATS II) is one of the efforts addressing the problems identified
above. SEATS is funded by the United States Agency for International
Development (USAID) and implemented by John Snow, Inc. (JSI) in
collaboration with its U.S. and in-country partners. The mission of
SEATS is to work with its partners and local organizations to promote
the development and expansion of high-quality, client-centered, sus￾tainable family planning and reproductive health services in developing
countries and to enhance access to these services.
SEATS works with communities where there is an expressed need and
is committed to building the capacity of these communities’ members
to sustain a better future. By offering innovative approaches and new
perspectives, SEATS increases the efficiency, effectiveness, and quality
of programs and helps reach groups of people who would otherwise
remain underserved. Quality of care is recognized as having a positive
effect on FP acceptance and use.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
3
Full access to, and use of, RHC
services provide women with a key to
their future, empowering them to
develop into fully productive citizens,
contributing to their nation socially,
culturally, and economically.
SEATS is linked to USAID’s Strategic Objective # 1: Increased use by
women and men of voluntary practices that contribute to reduced
fertility. An estimated 56 percent of the decline in fertility in the
developing world can be attributed to FP programs. Such programs
increase contraceptive use, promote breastfeeding, reduce reliance on
abortion, help prevent sexually transmitted infections (STIs), and
contribute to lower desired family size (USAID 1999).
SEATS Special Initiatives
The SEATS project developed five Special Initiatives to meet the
challenge of reaching underserved populations:
ª The nongovernmental organization (NGO)/private voluntary
organization (PVO) Integration Initiative
ª The Urban Initiative
ª The Youth Initiative
ª The Women’s Literacy Initiative
ª Midwifery Association Partnerships for Sustainability (MAPS)
The MAPS Initiative
MAPS contributes to the goal of increasing access to FP/RHC by
promoting the development of a particularly underutilized resource—
midwives. This Special Initiative is implemented by SEATS’ partner,
the American College of Nurse-Midwives (ACNM).
A professional organization for over 40 years, ACNM has extensive
experience working with midwives worldwide. Its expertise includes
strengthening midwifery associations, developing standards for
midwifery education and service delivery, enhancing national and
international networks, and advocating for reproductive health and
family planning.
Since 1995, MAPS has developed and implemented subprojects in
four countries in the Africa Region: Senegal, Uganda, Zambia, and
Zimbabwe. (See MAPS Country Project Summaries, Appendix 1.)
Also, MAPS has worked with midwifery associations in Cambodia,
Eritrea, and Tanzania—supporting their initiatives, involving them in
regional activities, and providing limited technical assistance (TA) at
their request. MAPS experienced a tremendous growth in the interest
in and demand for TA with private-practice midwives. This demand
came from midwives themselves due to their increased desire to be in
independent practice and from local USAID missions and Ministries of
Health due to the growing need for greater privatization of health services.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 4
One hundred percent of clients
surveyed would recommend their
Uganda Private Midwives Association
(UPMA) clinic to other clients.
Ninety percent of midwives felt that
cooperating with the community and
showing kindness were more satisfying
and productive than worrying about
their income.
UPMA Endline Evaluation
The time is right for MAPS. The economic burden of government￾sponsored health care and the diversion of government funds to meet
the burgeoning demands created by the AIDS crisis expand opportuni￾ties for private midwives. The increasing demand for high-quality RHC
and the growing privatization of health services (compounded by the
often low job satisfaction of service providers in the public health
sector) support the development of private midwife practices. Also,
cultural and legal changes are making it easier for women to own
property and pursue independent financial opportunities. At the same
time that opportunities for private midwives are growing, Ministries of
Health are instituting health reforms and redirecting policy focus to
decentralizing and improving quality of services. Since the majority of
FP/RHC services are provided by public midwives in Africa, MAPS and
the professional associations are well-positioned to offer such services
as continuing education and assistance to regulatory bodies in devel￾oping and monitoring standards.
MAPS as a Gender Initiative
It is significant to the work of MAPS that the vast majority of midwives
are women (for example, 95.5 percent in Zimbabwe). Women in
developing countries have lacked access to professional education, to
quality health care, to income-generating opportunities, and to advo￾cacy and political power. As a group, midwives have long been an
underserved population. Many midwives wishing to open their own
clinics have been denied access to start-up capital since they do not
own property to use as collateral. Also, most microfinance programs
that do serve women do not extend the level of credit needed with
realistic terms of repayment.
Strengthening midwifery associations allows midwives to practice
more independently. Strengthening MAPS-supported activities in￾cludes providing continuing education (CE) in business skills as well as
FP/RHC and advocating with regulatory agencies on behalf of mid￾wives. A byproduct of stronger associations is that individual midwives
gain courage and strength by working together in groups toward a
common cause.
Women increasingly seek out women providers for their most intimate
health needs. MAPS significantly increases the number of women
providing high-quality FP/RHC services in service delivery points
(SDPs) that are accessible to the clients.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
5
MAPS as a gender initiative: 95.5
percent of midwives in Zimbabwe are
women.
Publication Overview
This paper reviews MAPS’ ap￾proach with associations and their
member midwives; discusses the
rationale, process, and results of
MAPS strategies; presents lessons
learned; and explores the future
of MAPS. For illustration, the
MAPS project in Zimbabwe is
highlighted. Case studies and
examples from other MAPS
projects are also used to illustrate
particular segments. More
complete descriptions of MAPS
activities in each country can be
found in Appendix 1, MAPS
Country Project Summaries.

SEATS’
lessons learned from
MAPS I n i t i a t i v e
MAPS Increases Access by: Increases Access by:
ª Increasing the number of
private midwifery practices.
ª Identifying and supporting
aspiring private practitioners.
ª Reaching out to underserved
populations (e.g., men,
youth, miners, and farmers).
ª Expanding the FP method
mix.
ª Improving referral systems.
7
MAPS Approach
SEATS’ and ACNM’s experience has shown that when properly trained
and supported, midwives are dynamic forces for increasing access to
high-quality, sustainable services. MAPS works with midwives in the
private and public sectors through their professional associations.
Private-sector midwives are nationally certified midwives who have met
the requirements of local authorities and the national regulatory body to
own and operate independent clinics for profit. Most private midwives
offer integrated FP/RHC and minor curative services.
Midwives are a key part of solving the crisis of unmet need in FP/RHC.
This is true because:
ª Midwives are comparatively well-educated and have chosen
to work in women’s reproductive health.
ª Midwives are already in place—living and working in urban
and rural areas and reaching clients often not served by
public-sector programs and facilities.
ª Because there are many more midwives per capita than
physicians, midwives are more readily available to women in
urban and rural areas.
ª Midwives are trusted in their communities, often elected as
community leaders.
ª By training and inclination, midwives regard reproductive
health as an integrated whole, viewing women’s health needs
across the life cycle.
ª Private midwives offer affordable services and decrease the
demand on the public sector.
MAPS provides a unique opportunity to build the institutional capacity
of local midwifery associations. This focus on associations strengthens
the technical and policy support needed to maintain high standards of
quality and promote service expansion. Through training programs,
advocacy, policy formulation, and other innovative activities, such as
the use of a continuous quality improvement (CQI) approach to
develop “best practices” clinics, MAPS helps to ensure that this com￾munity-based resource achieves its full potential.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 8
MAPS is about partnerships—in linking professional associations and
their member midwives through regional activities such as workshops
and study tours; in encouraging participation in international confer￾ences and technical assistance (TA) by midwives from other associa￾tions and countries; and in developing communication vehicles, such
as newsletters and journals, that keep midwives connected to each other.
Three Levels of Association Development Three Levels of Association Development
The MAPS Initiative works primarily through midwifery associations to
support expanded, quality service delivery. MAPS supports these
associations as they became stronger and more capable of meeting the
needs of the people in their country. Association development activi￾ties are implemented at three levels, as shown below.
The MAPS Initiative works primarily through midwifery associations to support service delivery. Although there are many ways to
access private-sector midwives, on option—Association Development— is detailed below. The MAPS Initiative also encourages
other innovations to meet specific country needs, including franchising or working through informal networks of midwives. LEVEL 1 LEVEL 2 LEVEL 3
Association Development Family Planning/Reproductive Health
➤ Needs Assessment & Strategic Planning
➤ Leadership Development
➤ Training of Trainers
➤ Procurement & Logistics
➤ Monitoring, Supervision, Evaluation
➤ Liaison with National MCH/FP Programs
➤ F, P, MCH, Women's Health
STDs/HIV Overview
➤ Counseling & Client Information
➤ Service Provision Training for:
• Lactational Amenorrhea Method (LAM)
•s Barrier Method
•s Oral Contraceptive
➤ Traditional Practices & Beliefs
➤ Infection Prevention & Control
➤ Referral for Hormonal & Long-term Methods,
STDs/HIV Services & Pregnancy Care
➤ Recordkeeping
Ag ssociation Development FV amily Plannin Sh TD & HI Maternal and Child Healt
➤ Program Planning & Implementation
➤ Budgeting & Audit Preparation
➤ Recordkeeping & MIS
➤ Training of Trainers
➤ Establishing Referral Networks
➤ Membership-targeted Programs
• Business Skills
• Community Mobilization
➤ Service Provision Training for:
• Injectables
• Natural Family Planning (NFP)
➤ Counseling
➤ Referrals
➤ Recordkeeping
➤ Prevention & Management
➤ Counseling
➤ Referrals
➤ Recordkeeping
➤ Normal Antepartum
➤ Intrapartum, Postpartum
• Life-saving Skills
•s Partograph
• Newborn Assessment
• Breastfeeding
➤ Counseling
➤ Referrals
➤ Recordkeeping
Ag ssociation Development Family Plannin Maternal and Child Health
➤ Proposal Development
➤ Marketing & Fundraising
➤ Computer Skills for MIS
➤ Training of Trainers
➤ Advocacy within International Networks
➤ Liaison with National MCH/FP Programs
➤ VCS Program Design
➤ Service Provision Training for:
• IUDs
• NORPLANT®
➤ Counseling
➤ Referrals
➤ Recordkeeping
➤ Service Provision Training for:
• Life-saving Skills
(Emergency Obstertrics)
➤ Counseling
➤ Referrals
➤ Recordkeeping
Midwifery Association Partnerships for Sustainability
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Lack of business training had proven
costly to several of the private mid￾wives before MAPS. In one situation, a
midwife, thinking to spare herself
costly mistakes, hired an accountant
to work with her. Within six months,
this accountant owned her clinic and
wanted her as his employee.
9
Zimbabwe: An Illustrative Example Zimbabwe: An Illustrative Example
MAPS’ approach to expanding access to FP/RHC services by strength￾ening the role of midwives is implemented in different ways in each
country where the project operates, based on the unique situation and
conditions there. This strategic approach can perhaps best be illus￾trated by describing how the initiative works in a particular country.
The MAPS subproject in Zimbabwe serves as a comprehensive ex￾ample of MAPS’ activities and accomplishments. This section provides
the framework for the Zimbabwe subproject; subsequent sections
provide more details about MAPS’ implementation in that country.
Background
The primary provider of family planning services in Zimbabwe, as in
most of sub-Saharan Africa, is the government. The Zimbabwe Na￾tional Family Planning Council (ZNFPC), a parastatal under the Minis￾try of Health (MOH), provides approximately 85 percent of the avail￾able family planning training and services in Zimbabwe. The private
sector provides only a small portion of these services [12 percent
according to a 1996 study by the Promoting Financial Investments and
Transfers Project (PROFIT)].
Faced with a burgeoning demand on public-sector facilities, a growing
financial burden on the government, inadequate numbers of service
providers, a prevalence of short-term family planning methods, and a
growing HIV/AIDS epidemic; Zimbabwe sought new approaches to
RHC delivery. One logical approach was to explore ways to expand
the potential of the private sector. This approach was consistent with
the population strategies of the government of Zimbabwe, ZNFPC, the
USAID Mission, SEATS, and PROFIT.
In 1996, just before the MAPS project began, very few nurses and
midwives were in private practice in Zimbabwe, but interest was
growing. The PROFIT project (at the time the coordinating agency for
all activities being funded by USAID in the private sector in Zimbabwe)
conducted a study in January 1996 of the private sector’s contribution
to FP services in Zimbabwe. The results of the study documented that
private midwives were an untapped resource for delivering FP/RHC
services and that developing this group as a resource should be ex￾plored. At the time, PROFIT could find only six practicing private￾sector midwives. This study also documented the perceived con￾straints and barriers to practice.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
“Greater and more effective provision
of services by the private sector is
critical at this juncture. The private
sector itself is well organized and has
articulated an interest in increased
involvement. However… policy
reform, the removal of medically
unjustified restrictions on the role of
nurses…is a prerequisite to greater
participation.”
USAID Results Framework
“At first, I had been practicing in
a ‘hiding’ manner. MAPS brought me
out of isolation…. I’m able to work
wholeheartedly in an environment that
is very conducive. I also now have
skills to impart better FP information
to clients.”
Zimbabwean midwife
10
Private, independent nursing practice is a relatively new option for
nurses and midwives in Zimbabwe. At the outset of the MAPS Initia￾tive, many practicing midwives were virtually invisible, reluctant to
come forward, fearing retaliation or reprisal from regulatory bodies.
While these agencies did not explicitly prohibit midwifery practices,
they also did not openly permit them. Many regulations were ambigu￾ous at best, leaving the midwives with a sense of risk and insecurity.
Initially, the midwives were reluctant to disclose financial data and
were not keeping service statistics or credible business records.
Linkages to PROFIT, SEATS, and USAID Strategies
The main objective of the USAID/Zimbabwe three-year strategy for
1996–1999 was to reduce fertility and increase the use of HIV/AIDS
preventive measures (USAID Results Framework, Strategic Objective #3).
At the start of the MAPS/PROFIT collaboration, three areas of opportu￾nity were apparent: standardizing procedures for establishing private
practices, informing national and municipal authorities of these proce￾dures, and developing lending mechanisms to provide start-up capital
for new practices. Activities were targeted to achieve the following results:
ª Improved quality of family planning services.
ª Adequate supply and proper management of contraceptive
logistics (including the introduction of a social marketing
program).
ª Improved policies for reproductive health.
ª Expanded behavior change communication interventions in
HIV/AIDS/STIs to specifically address women and young
adults.
ª Expanded number of service providers in urban and rural
areas, using the MAPS Special Initiative capability.
Despite the many impediments they encountered, some nurses and
midwives had pioneered into the private sector and developed private
practices and collegial relationships with doctors and pharmacists.
Initially, little information was available about who these professionals
were, where they were practicing, what services they provided, and
how they managed to resolve the inherent difficulties of private practice.
The MAPS’ subproject in Zimbabwe explored opportunities for working
with active and retired nurses and midwives in the private sector.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Barriers to Practice Identified by the Special Study
Nurses and midwives feel that being able to provide immuniza￾tions and simple medications to their clients is an important
service, one that they were responsible for providing when
working in the public sector, yet once in private practice, they are
denied the right to provide.
MAPS Special Study
Midwives view private practice as a way
of being able to provide higher-quality
services, which includes having more
time to meet client needs and offering
more personalized care.
Clients seek the services of nurses and
midwives because the care is felt to be
convenient, personalized, and friendly.
MAPS Special Study
11
MAPS Special Study: The Role of Nurses and Midwives
in the Zimbabwe Private Sector
Over a four-month period in 1996, MAPS designed and implemented
an exploratory study that focused on nurses and midwives who were
practicing privately in Zimbabwe (Special Study Report, The Role of
Nurses and Midwives, Zimbabwe Private Sector 1996). The purpose of
the study was to learn more about the roles of these practitioners, the
services they provided, and the factors that facilitated and/or con￾strained their ability to practice effectively. By review of the Registry of
Private Midwives and by word of mouth, 22 practicing and 30 aspiring
private midwives were identified.
In addition, data were collected from 61 clients who sought services
from private nurses and midwives, from selected professional associa￾tions and organizations that might influence this type of practice, and
from nurses and midwives who were aspiring to enter private practice.
The results of the study, and the recommendations generated from the
results, served as a basis for developing the MAPS Zimbabwe sub￾project and provided guidance to stakeholders for planning interven￾tions creating a more favorable climate for private practice (see Special
Study Recommendations, Appendix 2).
Barriers to practice, sometimes subtle, often
overt, handicap the work of PMWs. Among
the barriers in Zimbabwe were professional
attitudes that affected the governance of
private midwifery practices. For example,
regulations permitted the dispensing of
contraceptives by community health workers,
but prohibited the dispensing (and even the
purchasing) of such commodities by licensed
private midwives.
The Special Study also identified restrictive
legislation on medication prescription—including medications clients
could buy over the counter. This restriction created a double standard,
since these drugs are ordered and given by nurses in the public sector
and in most rural health centers. Health workers and community￾based distributors are also permitted to dispense these drugs—under
supervision of nurses.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 12
The Project Begins
MAPS developed a partnership with the Zimbabwe Nurses Association
(ZINA) to implement activities for its members in Zimbabwe. This
subproject ran from January 1997 to July 1999. Its first major activity
was aimed at helping midwives overcome their sense of fear and
isolation. A three-day dissemination workshop was held in June 1997
to present the results of the Special Study. PMWs as well as represen￾tatives of health and social agencies were invited to attend.
The workshop provided midwives with an opportunity
to meet and interact with each other. They also had a
chance to interact with agencies, groups, and individu￾als perceived to be obstructive—such as the Drug
Control Council, the MOH, Medicaid Societies, phar￾macists, and physicians. Representatives from each of
these groups presented the roles and regulations of
their agency relative to PMWs, and midwives explained
their work and how it was affected by existing regula￾tions. These dialogues had a major impact on chang￾ing attitudes and demonstrated the PMWs’ desire to be
within the regulatory framework.
The Independent Clinics Organization (ICO)—a special￾interest organization that had recently been formed
under the umbrella of ZINA to provide a forum for the
special needs of PMWs—participated in the conference
and became the focus of the MAPS/ZINA project.
As a follow-up to the workshop, monthly ICO educa￾tion sessions, coordinated in conjunction with Popula￾tion Services International (PSI), were offered to new
members to provide information on oral contracep￾tives, the female sheath, male condoms, and social
marketing.
Immediate Results of 1997 Workshop to
Disseminate Special Study Findings
ª ICO grew from three to 50 members.
ª All 50 midwives attending the workshop were provided
with training in social marketing and supplies of oral
contraceptives and the female sheath.
ª ZINA increased its membership significantly, including
new members and many past members who had de￾faulted.
ª The Public Service Medical Aid Society (PSMAS) agreed
to issue billing numbers to PMWs, allowing them to bill
directly for their services.
ª PMWs became identified as a provider group clearly
seeking to be within the regulatory framework.
ª The Minister of Gender Issues became the patron of the
midwives.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 13
MAPS Strategies
To help programs meet their goals of enhancing the role of private- and
public-sector midwives, the MAPS Initiative first identifies existing
midwifery or nursing associations with which to work, conducting an
assessment of their critical needs. MAPS then works with the associa￾tion to design and implement a subproject to address these needs.
Next, MAPS hires a subproject coordinator who works at the associa￾tion to implement and administer the project.
While MAPS offers a flexible approach when working with these
associations, it consistently applies five strategies to the specific needs
of midwives and midwifery associations in each country:
1. Capacity building of associations.
2. Capacity building of members.
3. Creation of a more enabling practice environment.
4. Integration of quality and sustainability.
5. Policy initiatives.
I. Capacity Building of Associations
Improving the capacity of midwifery associations strengthens the
ability of individual midwives to provide high-quality services to their
clients. Associations often need support in self-governance, manage￾ment, training, advocacy, diversification of funding sources, strategic
planning, and marketing. After assessing an organization’s current
capability and identifying areas of weakness or strength, MAPS assists
the organization in the following areas:
ª Member surveys and computerized membership databases.
ª Member services, including such activities as producing
newsletters and coordinating regional workshops.
ª Strategic planning.
ª Development of sustainability and business plans.
ª Management training and development and strengthening of
Board of Directors.
ª Management information systems (MIS) and computerization
of financial management system.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 14
ª Information, education, and communication (IEC) and market￾ing training capability.
ª Policy reform.
ª Creation of a more enabling environment for expanded
practice roles.
ª Coalition building.
Member services is a key part of association capacity building. MAPS
works with association leaders to emphasize the importance of meet￾ing member needs and then to develop tools such as member surveys
and databases as a first step in identifying and meeting these needs.
These tools help associations ensure that their programs remain
relevant to their members and enable them to draw on the strengths of
each individual. MAPS works with midwifery associations to foster a
sharing of information and experiences; to provide continuing educa￾tion, seminars, and technical updates; and to develop training capabil￾ity within the associations.
Coalition building is another important aspect of MAPS’ work with
associations, as described in the Case Study on the next page. MAPS
encourages partnerships—linking professional associations with each
other, with existing resources, and with key stakeholders. As a result of
this initiative, midwifery associations have begun to communicate with
each other through publications such as newsletters and journals, and
more recently, e-mail. Links have also been developed between
associations and local, national, and international resources as well as
with stakeholders such as clients, community leaders, and Ministries of
Health and Gender.
“South-to-south” collaboration has been a major networking effort for
the midwifery associations participating in MAPS. This strategy in￾volves making use of skills and resources from other developing
countries instead of relying on TA from the north. An example of this
networking is the business management and community mobilization
training carried out for midwives in Zimbabwe by the trainers from
Uganda. Through networking, midwives reach across backyards,
townships, and country borders and join with other midwives in their
effort to expand quality reproductive health care for women. Also, this
approach extends MAPS’ impact beyond its subprojects. For example,
the president of ZNA shared the skills she learned from SEATS/MAPS
with the midwifery/nursing association in Tanzania. The ZNA presi￾dent shared new knowledge and skills in how to 1) develop and
expand association membership services, 2) ensure program
sustainability, 3) develop a strategic plan, and 4) improve quality.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
CASE STUDY:
Coalition Building Through a Study Tour
In October 1998, MAPS facilitated a study tour in Uganda for 24 PMWs from
Senegal, Uganda, and Zimbabwe. The objectives of the study tour were to:
ª Enhance the exchange of ideas and experiences through facilitating
group discussions and providing on-site observations of clinical
practice.
ª Improve the quality of and access to FP/RHC services by sharing
lessons learned.
ª Develop a collaborative relationship for ongoing networking among the
three associations.
The tour included: our included:
ª A visit to the Uganda Private Midwives Association (UPMA) headquar￾ters and the association’s new model clinic site in Kampala.
ª A workshop to discuss private-practice issues.
ª Three days of living and working together at the UPMA midwives’
clinics and homes, with ten ZINA midwives and two Senegalese
midwives paired with twelve UPMA midwives.
ª A presentation of individual quality workplans the final day
of the tour.
The Uganda study tour was the biggest south-to-south undertaking.
Details of the tour were published in the June 1999 Partnership in Popula￾tion and Development South-to-South Newsletter (see Appendix 5).
15
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Based on what she learned, each midwife identified quality improvement
action plans to be implemented at her clinic. Some of the actions identified
were to:
ª Increase capital in the clinic to “uplift the standard.”
ª Start a library where nurses can have access to current nursing and
medical information.
ª Improve the referral system by following clients and encouraging client
feedback.
ª Spend some nights at the clinic to properly monitor staff and
provide closer supervision.
ª Construct simple incinerators.
ª Provide suggestion boxes to allow clients to freely voice problems they
face, or offer suggestions or compliments to the staff.
ª Provide all RHC services including FP and immunization
under one roof.
Results of Study Tour Action Plans
A six-month follow-up of 22 of the 24 midwives (due to communication
difficulties and distance, the Senegalese midwives could not be reached)
revealed the following:
ª Ninety-one percent of the study tour midwives had implemented more
than half of their intended quality actions.
ª Some actions, though not complete, were in process. Delays were
experienced in obtaining permits for such services as immunizations
and in addressing such costs as expanding services to include maternity
care.
While the tour achieved many goals, its greatest success was in coalition
building. Through the study tour, associations from three different countries
learned about each other, learned from each other, and created connections
they used to continue strengthening their own work and each other’s. This
neighbor-to-neighbor form of collaboration is more likely to survive beyond
the life of SEATS than collaboration with a U.S.-based agency, providing a
sustainable mechanism for continued improvements and networking.
(See Uganda Study Tour Action Plan, Appendix 3, for more information.)
16
SEATS’
lessons learned from
MAPS I n i t i a t i v e
New Tools for New Roles
ª Business Management Skills for Private Midwives
Curriculum
ª Community Mobilization for Private Midwives
Curriculum
ª Handbook for Aspiring Midwives
ª Standards for Private-Practice Midwifery
ª Family Planning Referral Guidelines
ª Computerized Membership Database
“When I am involved in my commu￾nity, I am much more successful.”
ZINA/ICO member
II. Capacity Building of Members
Since an association is only as strong as its combined
members, MAPS also focuses on improving the
capacity of individual midwives.
Training is a central part of this strategy. PMWs need
new skills to become successful providers and
entrepreneurs. MAPS’ training focuses not only on
FP/RHC skills, but also on areas such as quality
improvement, staff management, profit and loss,
competitive marketing, and leveraging.
The table included in this section lists the workshops
conducted through MAPS and the number of mid￾wives trained in each. In addition to these work￾shops, several local and regional workshops were
held to disseminate current updates on FP/RHC
service provision and on the sustainability of PMW
practice. Thirty-four representative midwives from
MAPS Project countries attended the international
MAPS Dissemination Workshop in Zimbabwe in
June 1999.
MAPS also goes beyond training to help position midwives as agents of
change—in midwifery training institutions, in regulatory bodies, in such
organizations as the East, Central, and Southern African College of
Nursing (ECSACON) and the International Confederation of Midwives
(ICM), and in the donor community.
Business Management and Community Mobilization
To assist midwives who own and operate small RHC clinics in learning
basic concepts and skills for managing their businesses, MAPS pre￾pared and field-tested Business Management Skills for Private Midwives
Curriculum (MAPS 1997) and the companion Community Mobilization
for Private Midwives Curriculum (MAPS 1997).
The business management curriculum (21 hours of instruction) aims to
increase the sustainability of private-sector service delivery points and
emphasizes the correlation between continuing education, improve￾ments in the quality and scope of RHC services, and business viability.
Midwives learn to manage the resources of their SDPs more effectively
and efficiently by:
17
SEATS’
lessons learned from
MAPS I n i t i a t i v e
In Uganda, midwives took different
approaches to creating demand for
their services. One regularly visits the
marketplace in her community, and a
second goes to the bus terminals with
information about healthful behaviors
and services. Within six months of
Ugandan midwives carrying out their
community mobilization plans, 170
SDPs served by 145 midwives reported
a 10–20 percent increase in FP clients
per month.
18
ª Promoting their services and increasing the number of clients
who seek their services.
ª Keeping relevant business records and using the records to
manage, evaluate, and improve their business.
ª Accessing credit, evaluating the cost and benefits of extending
credit, and managing credit effectively.
ª Planning for their SDP using business records and knowledge
about the clients/community served.
The community mobilization curriculum (14 hours of instruction)
provides basic concepts and skills PMWs need to interact with their
communities. The curriculum stresses that, to be effective providers of
health services, midwives must be actively involved in the community.
Midwives learn to:
ª Become more familiar with community needs and resources.
ª Develop, implement, and evaluate action plans for problem
solving.
ª Create awareness of midwifery services in the community.
ª Collect and use data.
ª Develop and/or use IEC materials.
ª Develop a referral system for working with other service providers.
The use of competitive marketing principles, financial records, and
business and community action plans represented challenging and
exciting new ways of examining their situations, and—as described in
the evaluation section of this paper—many fledgling entrepreneurs
blossomed from this strategy.
Handbook for Aspiring Private Midwives
In Zimbabwe, many midwives expressed a growing desire to open
private practices and looked to ICO for advice and assistance. ICO
leaders, with MAPS TA, subsequently developed a Handbook for
Aspiring Private Midwives. The book covers topics essential to running
a private practice and includes a summary of relevant regulations.
In addition to being offered to aspiring private midwives, the handbook
was delivered to major stakeholders in an effort to keep communica￾tion flowing and to increase ZINA’s visibility. MAPS produced the first
200 copies, and ZINA will update and reproduce the handbook as needed.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Family Planning Training
The 1994 International Conference on Population and Development in
Cairo reinforced women’s needs for high-quality, integrated RHC. This
is a concept midwives have long understood. Priority areas for MAPS
RHC training include competency-based FP skills
development, STI/HIV counseling, community
mobilization, CQI, and business management skills.
In Uganda, MAPS training, conducted in collabora￾tion with the Delivery of Improved Services for
Health (DISH) project, is comprised of a six-week
comprehensive RHC training for private midwives.
The training proved to be a major resource for the
midwives—increasing awareness of, access to, and
use of their FP/RHC services. In Senegal, the Asso￾ciation Nationale des Sage-Femmes Sénégalaises
(ANSFS) training focused primarily on the lactational
amenorrhea method (LAM). In Zambia, midwives
were trained in youth-friendly services (YFS).
In addition to the training shown in the figure, MAPS helped the
midwives connect with training opportunities supported by other
assistance organizations. For example, PSI sponsored family planning
training for ZINA midwives in 1999; over 40 midwives received this
training during the year. Also, in Uganda, MAPS made vital links
between UPMA midwives and two important groups, the Social
Marketing for Change (SOMARC) Project and DISH. Over 300 Ugan￾dan midwives were trained in the social marketing of family planning
commodities by SOMARC. Also, through the DISH Project connec￾19
Priority areas for MAPS training include competency-based FP skills
development, CQI, community mobilization and business management.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
MAPS Training
Td opic Number of Midwives Traine
ZA INA U* PM ZS NA ANSF
F8 our-Week Basic FP 67 13
T 47 raining of Trainers (TOT)-FP/RHC or YFS 2
F5 P/STI Counseling 4
C1 QI 93
C2 QI ans Sustainability 3
C 211 QI Monitoring and Evaluation
Business Management and
Community Mobilization
34 8 28 3
TOT—Business Management and
Community Mobilization
7
S8 trategic Planning/Business Management 3
S6 ocial Marketing 6 Approx
300
S 2 2 22 trategies for Sustainable Development
L6 everaging 1 44
LAM Training 193
TOT—LAM 8
M5 anagement Supervision (SEATS I) 3
Y1 outh-Friendly Services 58
T2 OT—Youth-Friendly Services
F7 inancial Management
B5 ookeeping and Accounting
C5 omputer Training 1
*Zambia Nurses Association
20
SEATS’
lessons learned from
MAPS I n i t i a t i v e
CASE STUDY:
Serving Youth in Zambia
Three SEATS Special Initiatives—Urban, Youth,
and MAPS—were integrated in the Zambia
subproject. Implemented by the Zambia Nurses
Association (ZNA) and the Lusaka District
Health Management Team, MAPS/ZNA tar￾geted nurses and midwives in the public and
private sectors. The goal of the subproject was
to “strengthen the capacity of ZNA in order to
ensure the provision of quality sustainable FP/
RHC services to youth.” This was a somewhat
different focus than other MAPS projects. The
objectives of this subproject were to:
ª Increase youth knowledge of reproductive health and sexuality.
ª Train staff in youth-friendly approaches with quality care.
ª Create a supportive environment and increase youth utilization of available RHC
services in the seven SEATS-supported clinics of Lusaka.
ª Promote nurse/midwives’ involvement in STI/HIV prevention for youth at the commu￾nity level.
ª Provide regional workshops for nurse/midwifery association leadership focusing on the
potential role for private nurse-midwife service providers in Zambia.
To effectively reach midwives in Zambia, MAPS/ZNA conducted a TOT on youth-friendly
services for 47 participants, representing 27 of ZNA’s 42 branches. These individuals then
facilitated YFS update sessions throughout the country, ultimately reaching 501 nurses and
midwives.
A final evaluation of the MAPS/ZNA project was conducted in the spring of 1999. Results
showed a change in the midwives’ attitude toward caring for youth and providing FP/RHC
services to this population (see sidebar). Other indicators of provider improvement include:
ª Increased knowledge and skills of midwives (70 percent knowledge retention; 20 of
the 27 respondents scored 100 percent).
ª 11 of 14 stations sampled developed YFS sections.
ª The method mix increased from three options to seven.
ª Midwives took an active interest in participating in their communities, responding to
invitations from groups—such as high schools, parents’ groups, and civic groups—to
provide information on the RHC needs of youth.
“I have learned to treat
youth as individuals.”
“Previously, I felt it
was not right to
provide FP/RH
services to youth, but
now I feel this should
have been introduced
earlier.”
“I used to be surprised
when youth came for
FP, but now I under￾stand and they are
most welcome.”
“Youth have now
noticed that they are
welcome in our clinic.”
21
SEATS’
lessons learned from
MAPS I n i t i a t i v e
tion, 37 midwives received training during MAPS I, and 51 more during
MAPS II.
III. Creation of a More Enabling Environment
MAPS’ efforts to create more enabling practice environments for
PMWs have centered on reducing the barriers that keep midwives Service providers in Zimbabwe who
offer curative care are required to
obtain a National Medical Aid Societies
(NAMAS) billing number. This tariff
number enables the purchase of drugs
and medical supplies and the billing of
Medical Aid Societies. However,
billing numbers have not been provided
to midwives.
Without this number, midwives must
bill Medical Aid through their covering
physician, which means they are paid
four to six months after they send the
bill. This creates a difficult cash flow
problem for private midwives. Conse￾quently, nearly half of the practitioners
must find other means of work in
addition to maintaining their private
practice.
This situation also has emotional costs.
Several midwives described feeling
“humiliated” by having to constantly
ask for their money or “defeated” that
they are paid so much less for their
services than are doctors.
22
Need for accurate
information about
private practice
rules/regulations.
Sense of isolation.
Limited continuing
education
opportunities.
Reimbursement
for services.
Procurement,
prescription and
supply of family
planning commodi￾ties.
Need for recognition
of the role of private
midwives in helping
to meet health
care needs.
• Workshop held to promote dialogue between PMWs
and other stakeholders.
• Guidelines developed for PMW practice.
• Current regulations pertaining to PMW practice
summarized and disseminated.
• MAPS and ICO office established at ZINA headquar￾ters.
• Legal counsel engaged by ICO to represent mem￾bers.
• Information about the newly formed ICO provided
to members.
• ICO strengthened to address needs of members.
• Membership database developed to increase
communication between association and members.
• Regional and international activities carried out to
promote networking and communication between
associations.
• FP training provided to bring PMWs to national
standards: 85 percent met national standards in
1999 compared to 10 percent in 1996. Training
provided in business management, community
mobilization, social marketing strategies, and CQI. • Clinical updates (on topics such as dual protection)
provided at ICO meetings.
• Billing number obtained from Public Service Medical
Aid Society (PSMAS). • ICO advocating for improved tariffs and NAMAS
recognition.
• Link with PSI, which provided female sheaths. • ZINA links with PSI to become a subdistributor for
socially marketed commodities. • ProFam, a campaign to promote quality private￾sector services, developed logo and posters advertis￾ing FP services provided by midwives.
• Advocacy for change in restrictive regulations.
• Representation at meetings for FP/RHC. • Links developed with policy makers, educators, and
community leaders.
Barriers and Constraints to Private Practice in Zimbabwe
 Barriers Actions Taken
SEATS’
lessons learned from
MAPS I n i t i a t i v e
“Being known and respected for
providing quality care is the best part
of being in private practice.”
ZINA/ICO member
Of the 79 clients surveyed, 75 cited
quality of the services as the reason
they returned to a particular clinic.
Uganda Evaluation
23
In its subprojects, MAPS made intense, coordinated efforts to address
these barriers (see box on previous page, “Barriers and Constraints to
Private Practice in Zimbabwe”). By facilitating dialogues between
midwives and regulatory agencies, advocating for policy changes,
developing position papers, and creating links with other organiza￾tions, MAPS was successful in laying the groundwork for ongoing
efforts to reduce, and ultimately eliminate, these barriers.
IV. Integration of Quality and Sustainability
MAPS’ efforts to improve quality and enhance sustainability center on
the needs of the client. By providing services that meet client expecta￾tions and that are perceived to be of value, the quality of the service
and the likelihood of its continuation greatly improve.
Quality
Midwives are motivated to enter private practice primarily by their
desire to provide quality services to their clients. They also believe that
quality care is the best way to compete with other, similar service
delivery points.
To ensure quality, MAPS uses continuous quality improvement, or CQI,
strategies. CQI is a quality improvement methodology that empowers
organizations to undertake quality improvement on their own. It relies
on those who work in an organization and are most familiar with its
strengths and weaknesses to identify quality problems and develop and
implement solutions. CQI takes into account that many organizational
problems result from inadequate systems and processes rather than
from individuals. The methodology enables staff at all levels to work as
a team to analyze the systems and processes in which they work and
use the information to design and implement activities for improving
services.
The MAPS approach to CQI is built on the Bruce/Jain Framework for
Quality of Care in Family Planning Programs (Bruce 1990). It is data￾driven, involves the community, is client-oriented, and focuses on “best
practices”; the CQI team works together to improve the processes by
which they provide integrated reproductive health. A best practice is a
documented approach or technique that contributes to the highest
standard of FP/RHC service delivery. Best practices are validated by
research and, when used consistently, result in sustained positive
outcomes or improved performance.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Examples of Problems Solved
With a Suggestion Box
ª “Clients worried that the
doctor had been working
with ill clients, then coming
to the clinic. Solution: Solution: I Solution:
made him wear a new
overcoat with my clinic’s
name on it.”
ª “Our receptionist was
turning people away before
7 p.m. Solution: Solution: I talked to Solution:
her and convinced her to
keep accepting clients.”
ª “ZNFPC changed the cost
for oral contraceptives from
$5 per pack to $15; clients
wanted to know why.
Solution: Solution: Wrote a Solution: pamphlet
explaining the cost change.”
ICO Member
24
When asked how the quality of the services offered to clients im￾proved as a result of the CQI training, the midwives were quick to
identify the results. “After quality training,” explained one midwife,
 “I learned how to identify problems and solve them. Quality is not a
static thing: we must keep trying to improve.”
Tools that support the CQI process include:
ª Client surveys
ª Suggestion boxes
ª Decision-making matrix
ª Cause and effect diagrams
ª Tally sheets
ª Time and flow studies
ª Service statistics
ª Use of charts to graphically view data
ª Use of FP/RHC indicators
Each MAPS subproject developed a quality action plan that included a
problem statement, objectives and major activities, type of data collec￾tion used, indicators (sentinel or “key”), baseline levels, and achieve￾ments. The table on the next page “Quality Objectives and Achieve￾ments”, provides a sample of the positive change shown in all key
indicators for the subprojects.
Examples of the CQI Methodology in Action
Problem-solving techniques enabled the Houghton Park Private Clinic
in Harare, Zimbabwe, to address a situation that followed a rise in the
cost of oral contraceptives. The midwives noted a decline in FP clients
four months after beginning to keep statistics, from May to July of
1998. They also received six letters in the suggestion box with com￾plaints about the rise in cost of their oral contraceptive pill. The quality
team designed a questionnaire; 50 questionnaires were handed out to
clients attending the clinic, and 150 were distributed to community
residents. Of these 150 questionnaires, 110 were returned.
In the questionnaire, clients stated that they preferred to buy from the
public sector, where pills ranged between $5.00 and $10.00 per
packet. Although they were happy with the services they received at
the clinic, clients were choosing to save money. The midwives then
wrote a letter (see box). The strategy worked. Statistics for August to
December 1998 reveal a return to previous FP client levels.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 25
Achievements
74.1 percent of 25 midwives tested named five traits of
youth-friendly services compared to the baseline of 14.8
percent of 19 midwives tested. (“Evaluating the impact of
ZNA/MAPS interventions on reproductive health services
to the youth: Youth-Friendly Services.”)
Since the midwives had yet to develop action plans with
youth activities, the baseline was zero. SEATS/ZNA
conducted a follow- up of 14 facilities using observations,
informal interviews, and review of action plans and found
11 of the 14 facilities (79 percent) visited had operation￾alized some part of their action plans. (“Evaluating the
impact of ZNA/MAPS interventions on reproductive
health services to the youth: Youth-Friendly Services.”)
16.7 percent scored “excellent” or “very good” on baseline
assessment of referral practices.* Two months later, 93.3
percent scored “excellent” or “very good” on the same
endline assessment after development of and orientation
to referral guidelines.
• 100 percent of PMWs treated clients with respect.
• 97 percent provided adequate privacy.
• 89 percent gave correct information on how to use
method.
• 97 percent of clients had correct knowledge of how
to use their method.
• 94 percent of clients reported they felt comfortable
asking question remained (MAQ study).
• Standards for private midwives developed.
• 44 percent of midwives fully met at least three of six
new standards assessed; 93 percent received a
passing score on at least three of the new standards.
(Data from visits to midwives, various methodologies)
SEATS assisted, in some way, 77 midwives who were
aspiring to private practice. Major forms of assistance:
provided CE (primarily business management and FP/
RHC), provided assistance in obtaining equipment at
affordable cost, provided support/monitoring site visits,
and assisted with loans. A total of 73 midwives either
opened a private practice (N=48) or were preparing to
open a practice in the near future (N=25). MAPS suc￾ceeded in increasing the number of midwives in private
practice by 9.5 percent.
Objective
To increase awareness among 100
ZNA members of the RHC needs
of youth and knowledge about the
provision of youth-friendly RHC
services.
To enhance ZNA’s role in promot￾ing youth-friendly services by
nurse-midwives through at least
two national activities.
To enhance the referral capability
at 25 private midwifery SDPs in
order to provide a full range of FP
services.
To improve the provision of and
access to direct FP services in at
least 25 private midwifery SDPs.
To enhance UPMA’s role in
ensuring that all private midwives
meet quality practice standards.
To increase by 50 the number of
new SDPs opened or soon to be
opened by private midwives.
Z
N
A
Z
I
N
A
U
P
M
A
* Referral assessment included referral to known SDP; use of standardized referral letter; follow-up with client; *
separate referral record kept and noted in client record; reason for referral recorded; and contact information
available to all referring staff.
Quality Action Plans and Results
SEATS’
lessons learned from
MAPS I n i t i a t i v e 26
The Queen of Peace Clinic in Harare, Zimbabwe, noted a different
quality problem: clients complained of long waiting periods. In an
effort to address this concern, the CQI team asked the staff to move
clients through exams more quickly. Unfortunately, this approach left
the clients feeling “rushed.” The CQI team then elected to improve the
quality of the waiting time by adding a VCR and television to the waiting room
and showing health videos. As a result, 95 percent of the clients responded with
positive comments about the changes and the realization that their complaints
had been taken seriously.
Model Clinics
In Zimbabwe, MAPS developed model clinics to promote quality
service delivery. These clinics served as practicum sites for aspiring
private midwives and models for currently practicing PMWs. Model
clinics had the added benefit of providing transparency; they let other
service providers see what midwives do in order to diffuse some of the
professional jealousy.
Initially, the strategy called for developing two model clinics over a two￾year period. However, when project staff—armed with criteria for
selecting a model clinic—visited potential clinics, they found six sites
that met the criteria (see Criteria for Selection of Model Clinics, Appen￾dix 4). A decision was made to select all six private practice sites and
to create a Model Clinics Consortium to manage the TA needs of the
six sites.
The leaders of these six clinics gained much by collaborating with
MAPS and each other. They attained new positions of activity, advo￾cacy, and visibility. The experience of working in a group (the consor￾tium) toward a common goal empowered the midwives and renewed
their commitment and strength. They dared to try new activities. They
pooled their knowledge and experience during monthly meetings.
They became role models for other PMWs and aspiring private mid￾wives. As a result of MAPS, 18 model clinic sites are now operating in
strategic areas throughout Zimbabwe.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
CASE STUDY:
Developing a Model Clinic in Uganda
A UPMA-owned clinic evolved in response to two problems: the association
had insufficient operating funds and it needed to decrease its dependency on
donors. UPMA decided to build a nursing home that would offer a variety of
medical services in addition to maternity services. In Uganda, a nursing home
is a facility that provides a variety of inpatient and outpatient services. As part
of the feasibility study, UPMA considered the following:
ª A catchment area with good marketability of services.
ª Distance from competitors offering similar services.
ª Accessibility to public transport.
ª Number of women of reproductive age.
ª Expenditures on health services in the catchment area.
With TA from MAPS, DISH, and USAID/Uganda, UPMA identified a site
and developed financial projections for two years. The projections assumed a
two to five percent net growth rate, fees for services based on fees in similar
facilities, and recurring costs. During the design phase, UPMA leaders
involved the community and local council leaders, making them aware of the
services to be offered and eliciting their input.
UPMA expects the clinic to serve as an example of private-sector midwives
providing FP/RHC services. The clinic will also be a CE training site for
private- and public-sector midwives. In addition, it will provide visibility and
transparency for regulatory bodies, health care agencies, and other profes￾sional groups.
Since opening, the clinic has had a patient load ranging from a high of 299
the first month to a low of 157 during one month. The average number of
clients per month has been about 200. The reasons for visits range from
maternity care to general curative treatments for illnesses such as malaria.
Clients also come for family planning.
UPMA received funding through a local currency fund jointly administered by
USAID and the Uganda Ministry of Finance and Economic Planning. “The
Family Nursing Home,” purchased with this grant, opened June 30, 1999 (see
Appendix 5) with integrated RHC services. Full-scope midwifery, minor
curative services, and inpatient services are being provided, with plans to add
minor surgery (including surgical contraception), exercise instruction, and,
eventually, major surgery (e.g., caesarian sections). Technical assistance, in the
form of developing and implementing the clinic’s marketing strategies, is
being provided by the Commercial Market Strategies Project (CMS).
27
SEATS’
lessons learned from
MAPS I n i t i a t i v e 28
Sustainability
MAPS’ integrated approach to quality and sustainability combines a
process of continuous quality improvement and enhancement of
sustainability based on:
ª Team-based problem solving.
ª Involvement of clients, community members, and midwives.
ª Use of data in a cycle of planning, implementation, evaluation,
and feedback.
The SEATS definition of sustainability, which MAPS uses also, is the
capacity of an implementing partner to provide quality reproductive
health services at a steady or growing level to underserved populations
while decreasing dependence on external aid.
Two types of sustainability are germane to continued success of the
MAPS subprojects: 1) the sustainability of the associations and 2) the
individual long-term success of each provider.
Association Sustainability
The work of MAPS in strengthening the infrastructure of an association,
its bylaws, services, and expanded membership is enormously labor￾intensive and requires leadership of a very high caliber. The success of
MAPS is due in large part to the intensity and rigor of the technical
assistance provided to associations as well as to the dedicated, charis￾matic, and competent leadership of the project’s associations—ANSFS,
UPMA, ZINA, and ZNA. While not using a prescribed approach, each
subproject has included basic steps, most often in the same sequence.
MAPS developed this methodology to provide and sustain the skills
required to strengthen associations, efforts that had the potential for
benefiting over 9,000 midwives in the countries where MAPS is in￾volved. These components require intensive support during the first
few years to ensure the infrastructure can absorb and effectively use
TA. But once the knowledge and skills have been transferred and a
critical mass has been established, the energy of the whole is far
greater than its individual parts. The support includes:
SEATS’
lessons learned from
MAPS I n i t i a t i v e 29
ª Training
— Competency-based FP/RHC updates for the association
 members
— Financial management
— Proposal preparation
— Computer training
— Resource mobilization
ª Development of association-owned model clinics
ª Membership drives
ª Development of local, regional, and international linkages to
diversify the power base
ª Needs assessments
ª Leveraging
ª Strategic planning
Strategic planning is the process of examining the organization’s
current financial and organizational health to better envision the future
and develop the procedures and operations needed to achieve stated
goals. Developing a strategic plan is an ideal format for TA in training
managers. To make effective decisions, many factors must be weighed
in the organization’s environmental analysis, including:
ª Cultural factors
ª Economic factors
ª Status of current RHC services
ª Demand for services
ª Demographics
ª Access factors (infrastructure, policy and legislation,
political support)
ª Funding and donors
ª The organization’s staffing structure, governance, organiza￾tional policies and procedures, and current programming
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Couple-Years of Protection (CYP) and New
Acceptors
ZINA/ICO’s FP/MIS system allowed the association to
track CYP services provided by ICO members. Figures
show the total generated in ten quarters for ICO was
19,973—almost twice the original expectation of 10,000.
The total number of new acceptors was 52,121. The
model clinics contributed 22,916 new acceptors and
7,737 CYP to this total.
30
Several factors are potential barriers to association sustainability:
ª Volunteers do most of the associations’ work; associations do
not have a large number of staff.
ª Political and government changes affect the context of their
work.
ª Members have limited resources for supporting the associations.
ª Adequately training midwives in management skills requires
a high level of effort.
MAPS reviews the associations with a careful eye for existing and
potential issues likely to affect the performance of the organization.
Strategic objectives are then developed along several continuums:
growth, productivity, cost recovery, and/or efficiency.
In Zambia, the primary strategy used to accomplish ZNA’s
sustainability goals was building its institutional capacity in manage￾ment, finance, and leadership. To strengthen ZNA’s financial viability,
its staff was trained in accounting. The association branches con￾ducted “Community Health Checks,” which added to community
awareness and fundraising. Furthermore, because ZNA expanded the
services it offered its membership, it could increase membership fees
by almost 100 percent and collect on arrears.
ZNA also received a donation of funds from the
Norwegian Nurses Association that enabled it to
complete the purchase of an office building. This is an
example of yet another component of sustainability
that SEATS promotes: leveraging. Leveraging repre￾sents the association’s ability to use its assets—includ￾ing skills, expertise, and funds—to mobilize and diver￾sify its resources. Leveraging can be accomplished
through loans, contracts with other agencies, grants,
appropriate use of volunteers, individual donations, in￾kind service, or endowments. Sources for leveraged
funds may be as broad as multinational or government
organizations, or as narrowly defined as individuals or
nongovernmental organizations (NGOs). ZINA and
UPMA focus on diversifying their funding base and
therefore reducing their dependency on donor fund￾ing. With financial assistance from USAID, UPMA
operates an association-owned clinic and sells com￾modities to its members. Both activities serve as
vehicles for income generation. UPMA has also used
SEATS’
lessons learned from
MAPS I n i t i a t i v e
CASE STUDY:
MAPS/ICO Sustainability Plan
To achieve its sustainability goals, ICO developed four focus areas:
ª Continued improvement of the private practice environment.
ª Improvement of ICO management systems.
ª Expansion of ICO membership and services (see ICO Sustainability
Action Plan, Appendix 6).
ª Enhancement of revenue base.
ICO membership has grown from six midwives in 1996 to 186 midwives.
Members currently manage 136 SDPs in all 10 provinces of Zimbabwe. They
conduct monthly meetings, attended by an average of 35–40 members, that
feature CE presentations on such topics as clinical issues, managerial issues,
and professional advocacy. MAPS provided direct support through equipment
and/or training for 109 midwives, representing 85 SDPs.
ICO sustainability is enhanced by participation in activities that affect the
health care delivery system in Zimbabwe.
An executive officer of ICO and the MAPS/ZINA project coordinator have
been named to the Director of Pharmacy Services Task Force. This group is
focusing on issues of quality services and procurement.
With TA from MAPS, ICO prepared a proposal, Zimbabwe Sustainability for
Reproductive Health Care, to develop an ICO-managed model clinic. The
clinic would generate income while serving as a center of clinical excellence,
providing high-quality FP/RHC services and clinical training for PMWs in FP/
RHC.
31
its newly acquired proposal-writing skills to leverage funds from groups
other than USAID. Since 1998, UPMA has been awarded funds
totaling more than $232,000 for eight separate projects from groups
such as the World Health Organization (WHO), United Nations
Population Fund (UNFPA), Family Care International, CMS, and the
Ministry of Health/World Bank.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Follow-up to the business management
training showed that 92 percent of the
145 midwives trained were keeping
some financial records and service data.
Member Sustainability
“I most enjoy the continuity with
my clients. I can care for them for
many years, over the course of a
few pregnancies and in between.
I can also care for their children
and families.”
UPMA Midwife
32
MAPS promotes sustainability of individual midwives by improving
quality of care, strengthening PMWs’ marketing capabilities, increasing
access to FP care, and introducing user fees. The project facilitated
outreach activities by the PMWs to make communities more aware of
their services. Midwives reached beyond their clinics to the communi￾ties they served, and in so doing, learned a great deal about commu￾nity needs, perceptions of care, and barriers to access. In the MAPS’
evaluations, midwives cited the growth they experienced and satisfac￾tion they received through these outreach activities.
Also, helping midwives sustain their private practice includes teaching
them how to run a successful business. Midwives need to have skills in
filling out financial forms and keeping track of records and other
important documents. In training, they learn the importance not only
of keeping business records, but also of using these records to manage,
evaluate, and improve their business.
To handle basic accounting and develop budgets for action plans,
midwives need to understand financial management principles. Yet
they had a difficult time learning to plan and budget effectively. They
needed, and received, more practice sessions, supervisory visits, and
follow-up reviews than anticipated. The time, support, and monitoring
invested to support these new skills paid off. MAPS has been success￾ful in assisting PMWs to:
ª Access credit.
ª Evaluate the cost-benefits of extending credit and managing
credit effectively.
ª Use business records and knowledge about the clients and
community they serve to develop plans for their SDP.
ª Evaluate appropriate user fees and cost recovery.
Ensuring sustainability is a difficult process. Similar to associations,
individuals were also faced with challenges as they strove to make the
changes that would lead to their sustainability.
ª Access to start-up capital.
ª Access to affordable equipment and commodities.
ª Formal and informal restrictions to procurement of certain
commodities such as intrauterine devices and Norplant®
implants.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
One clinic in Zimbabwe meets the
needs of its clients for exercise, relax￾ation, and child care at the same
facility where they receive quality health
care. The midwife built a day care
center and fitness area. She provides a
qualified day care teacher and a trainer
for regularly scheduled exercise classes.
Men are beginning to use the facility as
often as women do. To support
working women who need to return to
work after exercise, she opened a
salon—with shower facilities and hair
stylists.
In another PMW clinic, the midwife
made her own beautiful bedding,
creating quiet and restful client rooms
to facilitate recovery. She also grows
the vegetables for the clients’ meals—
assuring fresh, tasty, and healthful
food.
33
ª Regulatory restrictions pertaining to dispensing curative drugs
and services.
ª Sufficient client volume.
ª Reimbursement for services.
Because of these constraints and others like them, the ZINA project
focused on reducing barriers to FP practice faced by nurses and
midwives in Zimbabwe. These barriers were particularly challenging in
Zimbabwe, since the nurses and midwives there are relatively new as
private practitioners.
To promote sustainability, midwives learned a new way to improve
their services—involving clients and the broader communities. They
learned to work with community leaders, seek the involvement and
support of families, and ask clients what they liked and did not like
about their care. This new way of working required a paradigm shift,
one that prompted midwives to seek new heights of personal courage
and new depths of support from each other.
Competitive marketing principles, financial records, and business and
community action plans were challenging and exciting new ways for
midwives to examine their situations. Many fledgling entrepreneurs
blossomed using these strategies. Several PMWs have found their
practices growing to the point that they have needed to open new
SDPs and hire other midwives and nurses.
These changes have also
brought some negative
repercussions. In Zimba￾bwe, one landlord signifi￾cantly increased rent for a
practice when he realized
the midwives were becom￾ing more and more success￾ful. Undaunted, the mid￾wives conducted market
research to find a new
location for their practice,
and they continue to thrive
at their new site.
MAPS promotes sustainability of individual
midwives by improving quality of care,
strengthening marketing capabilities and
increasing access to family planning services.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
“The miners are starved for health
information, but they must ‘foot it’ to
any site for care...so I get to the hole
before they go down…and talk to them
about condoms, family planning, and
STIs.”
ICO member
34
In spite of their need to earn an adequate income, midwives are particularly
sensitive to the plight of disadvantaged groups.
In spite of their need to earn an adequate income, midwives are
particularly sensitive to the plight of disadvantaged groups. Most
expressed a willingness to provide pro bono services to their clients
when necessary. This is, however, an area of concern for the viability
of their business.
One midwife from the Model Clinic Consortium in Zimbabwe serves a
client base that includes many mine workers. She devotes two days
per month to their needs—traveling to the mine to provide condoms,
treat STIs, and answer questions. The midwife’s goal is to approach the
management of the mine with an action plan for quality care, in the
hopes of negotiating a contract to provide a broader range of services
to the miners and their families and to be reimbursed for the commodi￾ties. Another model clinic midwife has a mobile clinic. She takes it to
community farms in the rural area of Zimbabwe she serves.
V. Policy Initiatives
Standards define competency and are written broadly enough to
apply to all practice settings. In contrast, guidelines, which define
the process of client care and its management, focus on client out￾comes and are based on scientific evidence, requiring frequent review
and updating.
MAPS developed standards for private midwifery services in Uganda.
These will serve as a model for other countries. An assessment is
currently being conducted in Uganda to determine the percentage of
sampled midwives who meet the standards. The results of this assess￾ment will guide future efforts.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Developing Standards for Private Practice
Standards are authoritative statements by which the... profession
describes the responsibilities for which its practitioners are
accountable. These standards reflect the values and priorities of
the profession and provide direction for practice and framework
for the evaluation of practice. Standards define the profession’s
accountability to the public and the client outcomes for which the
provider is responsible.
Taylor 1995
35
Family Planning Referral Guidelines
One of the key activities undertaken by MAPS/ICO was developing
referral guidelines for family planning clients. These guidelines were
important because PMWs found acquiring FP commodities increas￾ingly difficult and were restricted from inserting intrauterine devices
and Norplant® implants. Also, more clients were requesting voluntary
sterilization, which PMWs cannot perform. Midwives often needed to
refer clients seeking contraceptive services to appropriate SDPs. ICO
addressed this need by developing, testing and introducing a standard￾ized, efficient mechanism for client referrals.
Position Paper: Private Midwife
Practice in Zimbabwe
In response to the frustration of being
relatively invisible to Zimbabwe’s national
regulatory agencies and decision-making
bodies, the model clinic midwives devel￾oped a position paper on the status of
private midwife practice in that country.
They wrote the paper with assistance from
MAPS and the Director of Nursing Science
at the University of Zimbabwe.
The report is a situation analysis of the
current status of private practice in Zimba￾bwe, with suggestions for improvements to
promote the maximum contribution to
women’s health from private-sector nurses
and midwives. The Permanent Secretary for
Health, who has approved the paper’s
distribution to support grant applications
and funding requests to outside sources, is
very pleased with this document and its
articulation of the issues and barriers facing
private-practice midwives. The paper has
become the centerpiece for continuing
discussions with regulatory agencies, insur￾ance groups, and other stakeholders.

SEATS’
lessons learned from
MAPS I n i t i a t i v e
Lessons Learned
1. The power of quality should never be underestimated.
2. Flexibility and perseverance are needed to operate within
the constraints of a situation or country.
3. Every new situation should be treated as a teaching and
learning opportunity, with mid-course adjustments made
and midwives consulted for creative problem solving.
4. Barriers to private practice severely limit the potential
contribution of midwives to reducing the unmet need for
RHC services.
5. RHC services and SDPs that include FP/STI/HIV are
incomplete without minor curative services and immuniza￾tion capability.
6. In unity, there is strength.
7. HIV/AIDS has permanently changed the service delivery
environment.
8. Basic business management skills and community mobiliza￾tion skills are critical to the viability of private midwives.
9. Monitoring and long-term supervision of midwives on a
sustained basis is difficult.
10. Learning how to monitor quality takes time.
11. Private midwives serve existing needs.
12. Private practice expands service.
37
Lessons Learned
Despite the short-term nature of most of the subprojects, MAPS has
been highly successful in strengthening the capacity of associations
and the skills of midwives. Further, MAPS has been instrumental in
positioning midwifery associations and private-practice midwives as
significant change agents capable of delivering high-quality reproduc￾tive health services.
During the course of the project, MAPS
learned many valuable lessons. The points
below are meant to be illustrative rather than
definitive.
1. The power of quality should never be
underestimated.
A review of the subprojects’ evalua￾tion data reveals that quality counts.
Clients are willing to pay for quality
services; and satisfied clients return
and tell others about the care they
receive.
Midwives understand that the quality
of care provided to women, youth,
men, and families is important not
only to the clients, but to the midwives
themselves. Providing quality care
gives them a sense of pride in their
work; it also ensures greater financial
success. For many midwives, earning a
living wage and being able to pay their
children’s school fees were significant
accomplishments.
Private midwives are highly motivated
to deliver quality services because
their reputation in the community and
their livelihood are at stake.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 38
2. Flexibility and perseverance are needed to operate within
the constraints of a situation or country.
Flexibility and perseverance are mandates for MAPS project
development. This initiative experienced circumstances that
at first seemed discouraging, but later became manageable.
Several MAPS subprojects were plagued with difficulties
during implementation. For example, in Senegal, several key
staff resigned at a crucial time in the project and in Zimbabwe,
the cost of oral contraceptives increased threefold. Project
staff in each site had to deal with macro-level challenges such
as civil unrest, budgets eroded by unanticipated devaluation of
local currencies, adjustments required to support health-sector
reforms, persistent problems with communications and
overland travel, and the devastating toll of AIDS.
Tenacity, understanding, and support helped project staff
achieve results that at first seemed impossible. It is a testi￾mony to the quality of this TA that, despite numerous chal￾lenges, each MAPS subproject not only met, but exceeded,
its objectives.
3. Every new situation should be treated as a teaching and
learning opportunity, with mid-course adjustments made
and midwives consulted for creative problem solving.
Each subproject had a somewhat different focus, and each
association was at a different level of development. MAPS
offered a wide range of TA to fit specific needs. Because the
TA was highly specialized, and much of the training was
offered in areas unfamiliar to the midwives, careful coordina￾tion was needed. It was also important to ensure an adequate
length of time for each training (e.g., more time was needed to
transfer business and accounting skills than anticipated) and to
select consultants with appropriate expertise and language
facility.
4. Barriers to private practice severely limit the potential contri￾bution of midwives to reduce unmet need for RHC services.
MAPS worked diligently to reduce official barriers to PMW
practice. Advocacy became the critical skill for ensuring
success. Continued work to overcome barriers—particularly
those that prevent midwives from easily obtaining commodi￾ties and dispensing contraceptives, immunizations, and simple
medications in their SDPs—is key to continued sustainability.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 39
Unofficial barriers, such as fear of competition from other health
care groups, are much more difficult to address. Still, they
must be overcome if midwives are to contribute effectively.
5. RHC services and SDPs that include FP/STI/HIV are incomplete
without minor curative services and immunization capability.
To serve their clients adequately, midwives need to provide
minor curative services, immunizations, and comprehensive
maternity care. Without such capacity, PMWs lose opportuni￾ties to promote health and risk losing clients to systems that
provide these services. Many of the midwives’ SDPs are also
maternity care centers, and many midwives expressed an
interest in CE that addressed maternal health issues. Collabo￾ration with DISH in Uganda, and work with the SEATS/
MotherCare project in Eritrea and with the SEATS program in
Cambodia, provided opportunities for life-saving skills (LSS)
training in those countries. Midwifery associations in other
project areas could benefit from similar training in safe moth￾erhood skills. Perhaps UPMA’s model clinic could provide for
such training as an income-generating, south-to-south activity.
6. In unity, there is strength.
As a result of the MAPS Initiative, midwives in the project
countries are collectively stronger. They have a new way to
learn from, and support, each other. They can now view
problems as issues that need to be resolved, rather than
insurmountable barriers to their personal success.
By strengthening PMWs’ capacity to provide services and to
operate a sustainable practice and by organizing their collec￾tive efforts, MAPS has helped to empower midwives to
constructively advocate for policy issues. Where they once
hid from regulatory agencies, they now serve on policy￾making committees. Training midwives in these skills requires
intensive support, but once a critical mass is established, the
energy of the whole is far greater than its parts. For example,
the fact that the number of private practice midwives in
Zimbabwe grew from six to over 200 (more than 85 percent
of whom are ICO members) empowers ICO to move forward
with much greater visibility and effectiveness.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 40
7. HIV/AIDS has permanently changed the service delivery
environment.
The reality of HIV/AIDS affects midwifery practices as it does
all health and social systems. Midwives, their SDPs, and
midwifery associations must know how to counsel clients
affected by HIV/AIDS and, equally important, they must know
how to protect clients and themselves from cross-infection.
They must also learn how to deal with colleagues and staff
who become infected. The Model Clinics Consortium
struggled with this issue as one that affected quality of care
and access. Clients quickly became frightened of staff mem￾bers who appeared ill or thin and began to stay away from the
clinic or refused treatment from particular staff members.
Future MAPS initiatives will need to deal more extensively
with this complex crisis.
8. Basic business management skills and community mobiliza￾tion skills are critical to the viability of private midwives.
Even the most skilled service providers will have difficulty
succeeding in private practice without basic skills in business
management and community mobilization. Yet almost with￾out exception, private midwives lacked this training before
MAPS arrived.
MAPS found that the most difficult concept for midwives was
budgeting. Planning and managing finances with an eye to
the future is especially challenging when life circumstances
have promoted a day-to-day existence and when cultural
practices have prohibited women from handling money and
property of their own. Effective budgeting requires a change
in thinking—a change that must happen gradually. MAPS can
better support this change in the future by strengthening the
curriculum and offering more on-the-job follow-up and as￾sisted supervision.
9. Monitoring and long-term supervision of midwives on a
sustained basis is difficult.
Midwives are located in urban and rural communities and
often in underserved areas. Although one of the qualities that
makes them a valuable RHC resource, it also complicates
supervision. Professional associations, MOHs, and regulatory
bodies generally have limited resources for this activity.
Creative approaches to effective supervision must be devel￾oped (e.g., peer review or supervisory training of key person￾nel within the facilities or within a limited geographic area).
SEATS’
lessons learned from
MAPS I n i t i a t i v e 41
UPMA has developed a system of regional representatives who
were trained to provide on-the-job support, collect service
data, supply commodities, and provide a communication link
among the association headquarters, member midwives, and
the district offices of the MOH. MAPS is continuing to work
with UPMA on mechanisms to sustain these activities.
10. Learning how to monitor quality takes time.
Process indicators are easy and familiar ways to monitor
projects; output and impact indicators are much more diffi￾cult—not only for those who design projects, but also for
partners who implement them. When projects run for only
two years, assessing their impact is especially difficult. Assist￾ing project staff in effectively monitoring the quality of their
program is highly resource intensive. Therefore, more re￾sources need to be built into project designs and budgets
from the start.
11. Private midwives serve existing needs and reduce the public￾sector burden.
Private midwives provide affordable, quality alternatives to
care for clients who live in underserved areas or who cannot
access a private doctor but can afford to pay a reasonable fee
for services. The services they provide relieve some of the
burden on public-sector facilities and services.
12. Private practice expands service.
Private practice offers options to midwives who are leaving
public service and who otherwise would be lost to the na￾tional health care delivery system. It is a way to keep valuable,
experienced service providers within the health field.

SEATS’
lessons learned from
MAPS I n i t i a t i v e
Suggestions for the Future Suggestions for the FutureSuggestions for the Future
1. Maintain current strengths.
2. Maintain features of current
program.
3. Extend capacity building to
strengthen community
mobilization and NGO
linkages.
4. Empower midwives by
removing barriers to practice.
Since private midwives are often the primary providers of family health
services, they have the potential to meet people’s needs for reproductive
health care throughout their lives.
43
The Future of MAPS
Midwives have tremendous potential for reaching
underserved populations and for providing inte￾grated reproductive health services either onsite or
by efficient referral. Midwives are trusted members
of urban and rural communities, they understand the
needs of women, and—with training and support
from their associations—they are able to provide a
broad range of services. Since private midwives are
often the primary providers of family health services,
they have the potential to meet people’s needs for
reproductive health care throughout their lives.
The future of the MAPS Initiative lies in consolidating
what has been accomplished, while continuing to
build and expand on the project’s strengths and
achievements. Here are some of the main points to
be considered:
1. Maintain current strengths.
MAPS has successfully developed a capacity to respond with
flexibility to midwifery associations’ needs along a develop￾mental continuum. This approach takes into account each
association’s management capabilities and capacity to meet
member needs. The MAPS emphasis on quality and
sustainability increases client access, as well as client and pro￾vider satisfaction.
2. Maintain features of current program.
Continuing education for acquiring new skills in FP/RHC
service delivery, community outreach, and quality of care will
be needed until such skills are completely integrated into pre￾service training. Interventions to promote sustainability are
particularly important at the level of the association as well as of
the individual midwife. Training in business skills must be central
to any strategy.
To ensure high standards of quality, continued emphasis must
be placed on model clinic development and CQI process
implementation. The Model Clinic Consortium should be
replicated either by mentoring of association members by
Consortium midwives or through model clinic development at
association branches.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 44
3. Extend capacity building to strengthen community
mobilization and NGO linkages.
The MAPS focus on building institutional capacity of local
midwifery associations guaranteed the sustained technical and
policy support needed for maintaining high standards of
quality and promoting service expansion. This emphasis on
institutional capacity should continue as a central component,
and the focus should be expanded to move beyond current
boundaries.
Currently, providers do not have the funds or the expertise to
market prepayment plans or to develop the financial systems
required to manage such a plan. However, the future of
PMWs’ sustainability may well depend on MAPS TA in this
direction. Most clients who seek private practitioners are
covered by medical aid. As reimbursements for services
become more equitable for PMWs in the future, the financial
viability and sustainability of their FP/RHC services will in￾crease. Finding financial institutions willing to work on this
component will be key.
The community mobilization curriculum, while continuing to
provide the same core competency in working with the
community, needs to be expanded to include optional mod￾ules that would enable midwives to access certain key com￾munity populations, such as youth, working women, men, and
women-at-risk.
Linkages and expanded partnerships between midwives and
communities need to include more networking with the
public sector, further development of cross-training with other
projects or NGOs [e.g., the LSS training with DISH in Uganda
and the Zimbabwe AIDS Prevention and Support Organiza￾tion (ZAPSO) in Zimbabwe], and an increase in social market￾ing/market interventions. Partnerships between associations
and practicing and aspiring private midwives could be used to
promote mutual goals while limiting the isolation of success
and facilitating expansion as interest in private practice grows.
More emphasis is needed on regional and international
linkages and activities such as study tours, workshops, associa￾tion-to-association technical assistance, and collaborative regional
research.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 45
4. Empower midwives by removing barriers to practice.
Empowering women as providers and recipients of quality FP/
RHC creates autonomy and trust. As midwives develop the
capability to earn an adequate income that meets personal
and family needs, their autonomy provides a role model for
clients, especially adolescents. Working with their communi￾ties to improve health care and quality of services, midwives
become empowered to address such issues as female educa￾tion, maternal mortality, dual protection, postabortion care
and abortion prevention, and prevention of domestic vio￾lence.
In 1999, the government of Zimbabwe named a midwife, the
owner of the Queen of Peace Clinic, as Business Woman of
the Year. This is just one example that indicates barriers are
falling. MAPS is proud of her accomplishment and proud of
the role it played in increasing the visibility and success of all
the midwives involved in the project activities.
Cultivating sustainability in professional associations is a
developmental process and requires intense and varied
technical assistance. In the lifetime of an organization, it could
be said that MAPS is entering its adolescence. The next
phases of TA, then, will require different core objectives than
the early phases, yet they will be equally important. The
south-to-south collaborative work that began with ZINA and
UPMA as well as their model clinics is moving the two associa￾tions toward autonomy and interdependence as health
professional organizations. Association members have gained
many leadership skills and are mastering the networking skills
needed for continued strength. Ideally, the next phase could
include an articulation of the dynamics of the process and
progress to date, including the variations between associations
and their relationships to regulatory agencies.

SEATS’
lessons learned from
MAPS I n i t i a t i v e 47
References
Bruce, Judith. 1990. Fundamental Elements of the Quality of Care: A
Simple Framework. Studies in Family Planning, Vol. 21, No. 2:61-91.
Business Management Skills for Private Midwives: Curriculum and Guide
for Trainers. 1997. ACNM and SEATS. Prepared for the United States
Agency for International Development, Office of Population, Contract
CCP-C-00-94-00004-10.
Community Mobilization for Private Midwives: Curriculum and Guide
for Trainers. 1997. ACNM and SEATS. Prepared for the United States
Agency for International Development, Office of Population, Contract
CCP-C-00-94-00004-10.
Macro Interational, Inc. Eritrea Demographic and Health Survey 1995,
Maryland, USA, March 1996.
Marshall, M. and S.T. Buffington. Life-saving Skills Manual for Midwives.
Third Edition. Americ an College of Nurse- Midwives, 1998.
Family Planning Referral Guidelines. 1998. Independent Clinics Organi￾zation and Zimbabwe Nurses Association. Technical assistance pro￾vided by SEATS/MAPS.
The MAPS Initiative: Midwifery Association Partnerships for
Sustainability. 1999. The SEATS Project, John Snow, Inc. USAID-funded
brochure.
Position Paper on Private Nurse/Midwives Practice in Zimbabwe. 1999.
Independent Clinics Organization and Zimbabwe Nurses Association.
Technical assistance provided by Department of Nursing Science,
University of Zimbabwe and SEATS/MAPS.
Taylor, J.W. Implementation of Nursing Practice Standards and Guide￾lines. American Nurses Association. Pub. # NP-98.1995.
The PROFIT Study, Assessment of the Private Medical Sector in
Zimbabwe, January 1996.
Special Study Report, The Role of Nurses and Midwives, Zimbabwe
Private Sector. 1996. SEATS and PROFIT Projects.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
U.S. Bureau of the Census, Report WP/98, World Population Profile:
1998. 1999. U.S. Government Printing Office, Washington, DC.
U.S. Agency for International Development, Strategic Plan. 1999.
Bureau for Global Programs, Field Support and Research; Center for
Population, Health and Nutrition.
Computerized database user manuals for Uganda, Zambia, and
Zimbabwe professional associations. 1999. SEATS Project.
48
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Dates: November 1997–
January 1999 (Activities
ended in September
1998)
Cost: $56,400 (excluding
technical assistance costs)
Major Components:
ª Strengthen the administra￾tive capacity of the Associa￾tion Nationale des Sage￾Femmes Sénégalaises
(ANSFS).
ª Improve the training capacity
of ANSFS in reproductive
health service delivery.
Key Populations:
ª 13 service delivery points in
Dakar and Thies.
ª 230 midwives.
49
Appendix 1
MAPS Country Project Summaries MAPS Country Project Summaries
SENEGAL
Senegal is a Francophone Muslim country with a high fertility rate (5.7
children per woman of reproductive age) and high maternal and child
mortality rates (510 mothers die per 100,000 live births, and 139 per
1,000 children die before their fifth birthday).
The MAPS subproject in Senegal was implemented by of L’Association
Nationale des Sage-Femmes Sénégalaises (ANSFS). This national
association for midwives was founded in 1964, and approximately 90
percent (545) of all midwives in Senegal are members. However,
when MAPS came to Senegal, only 150 of the members were active
(i.e., they paid their dues on time and attended meetings regularly).
ANSFS did not have administrative space or office equipment; data on
members were organized in handwritten files.
Also at this time, there was no formal management of training pro￾grams for clinicians at the national or regional level, resulting in a wide
variation of practice standards, which were often poor. Clinical up￾dates and continuing education were not consistently available for
Senegalese midwives nor were they a requirement for practice.
The purpose of the MAPS/ANSFS subproject was to improve FP/RHC
service provision by midwives and to strengthen ANSFS’ administrative
and training capability. The MAPS/ANSFS collaboration targeted 13
SDPs. Vital to the growth of the association was the development of
ANSFS administrative and training capability. Specific objectives
included:
1. Strengthen ANSFS institutional administrative capabilities:
ª Develop and implement a strategic plan and membership
support activities.
ª Develop an income-generation plan.
ª Develop, implement, and analyze a member survey.
ª Develop an MIS system, starting with computerization of
member data.
ª Orient ANSFS leaders to business management.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Highlights
ª LAM TOT, LAM training (193 midwives/nurses),
and follow-up.
ª Significant increase in LAM acceptors, from 361 in
the fourth quarter of 1997 to 710 in the third
quarter of 1998.
ª Computerization of membership data.
ª Participation of 90 percent of members in survey.
ª Business management training for eight ANSFS
leaders.
ª Development and implementation of ANSFS
strategic plan.
ª Participation in regional quality workshop.
ª 14 SDPs improved.
ª Developed trainer expertise through training of trainers
(TOT).
ª Trained eight midwives in lactational amenorrhea
(LAM) and breastfeeding updates.
ª Sponsored ANSFS leaders to attend a quality of
care workshop.
ª Developed a training database.
50
ª Sponsor at least two ANSFS leaders to attend a
sustainability workshop.
2. Increase ANSFS members’ training capability
and provision of RHC services.
LAM training was included based on the results of the
needs assessment. Eighty percent of the midwives in
the two project regions identified LAM instruction as a
training need. In addition, breastfeeding practices in
Senegal were not considered optimal, and the National
Family Planning Program had launched a major strat￾egy to promote breastfeeding. MAPS/ANSFS planned
to train 89 midwives in LAM, but the project suc￾ceeded in training 193 midwives and maternal child
health workers.
Since it will be some time before ANSFS can operate
without some level of donor funding, MAPS provided a
workshop in proposal writing and assistance in writing
a simple proposal. MAPS also assisted ANSFS in
developing a sustainability plan.
Three main factors were responsible for the achieve￾ments in this subproject:
ª The commitment of a core group of ANSFS
members.
ª The expertise of the MAPS consultant (prob￾lems were encountered in placing a long-term
consultant in this project; however, the short￾term consultant’s significant expertise in
project management and her multilingual
capacity enabled her to effectively assist with
project activities).
ª SEATS’ commitment to the development of
ANSFS.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Dates: April 1998–December 1999
Cost: $342,191 (excluding technical assistance costs)
Major Components:
ª Strengthen the Uganda Private Midwives Associations
(UPMAs) ability to assist midwives in establishing,
operating, and sustaining private practices.
ª Establish UPMA as a center of excellence for in-service
training of midwifery and reproductive, maternal, and
infant health services.
ª Enhance UPMAs financial self-sufficiency and manage￾ment capacity.
ª Develop linkages between UPMA and other mid￾wifery associations.
ª Develop a model clinic and training site.
Key Population:
ª 800 private midwives of Uganda (approximately 500 are
members of UPMA). This subproject was designed to
support the USAID bilateral program, Delivery of Im￾proved Services for Health (DISH).
51
Constraints of the MAPS/Senegal Project
The project in Senegal faced several challenges:
ª Unexpected resignation of the MAPS local consultant due to
unforeseen family relocation.
ª Lack of a project coordinator/consultant for over six months.
ª Significant language barrier (since this was the only MAPS
project in a Francophone country, there were several disad￾vantages: missed regional opportunities for networking;
limited written materials in French; communication with
MAPS technical assistance providers, Africa Regional Office,
and JSI/Washington was difficult).
ª Early termination (the project ended four months early) due to
revisions in the USAID/Senegal strategy.
ª A shift in priorities by ANSFS, which
affected the association’s ability to
complete the program’s objectives.
UGANDA
Uganda has made major inroads in decreasing
its total fertility rate—currently at 6.9. The unmet
need for contraception is estimated to be 29
percent. STIs are prevalent in Uganda, account￾ing for 20 percent of all outpatient visits. Life
expectancy may be the lowest in the world, 37
years of age, due primarily to the AIDS epi￾demic. It is estimated that 1,900,000 Ugandans
(out of a total population of 20,000,000) are
infected with HIV. As a result of many years of
political instability from civil war (1966–1987),
many midwives are also in need of FP/RHC
skills updating.
Private midwives (PMWs) have a long history in
Uganda; they have been providing preventive
and curative services as well as antenatal,
delivery, and postnatal services for more than
50 years. Private midwives have the potential
for significantly expanding the efforts of the
government of Uganda to provide accessible,
quality RHC services nationwide. Although the
private sector in Uganda is critical to meeting
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Highlights
ª Over 160 SDPs improved.
ª Increased access to FP
services.
52
the growing demand for RHC needs, the number of private facilities
and practitioners is limited. At present, PMWs are the only private
health practitioners that are operating in rural and urban communities
nationwide—making them a significant health care resource.
Midwives retiring from public service as well as new midwifery gradu￾ates are increasingly interested in entering private practice. Most of
these women need to work to support large families or to supplement
an inadequate pension. Many women have become sole supporters
of extended family members who are victims of AIDS.
Started by 12 midwives in 1948, UPMA is a registered nongovernmen￾tal organization (NGO) in Uganda and a member of the International
Confederation of Midwives (ICM). Membership is open to all trained,
self-employed midwives who have at least five years experience.
UPMA plays a key role in promoting the professional development and
socioeconomic welfare of its members through training and access to
credit. UPMA is the potential link for accessing, monitoring, and
assisting PMWs, as well as expanding the number of practitioners
providing high-quality RHC.
SEATS/UPMA Collaboration
SEATS, through ACNM, has been providing technical assistance to
UPMA since 1991 through the following projects:
ª SEATS I
ª SEATS II/MAPS I
ª SEATS II/MAPS II
The objectives of the effort have been to:
ª Increase by 10 percent the number of midwives in private
practice through enabling the UPMA to assist midwives in
establishing, operating, and sustaining private practices.
ª Establish UPMA’s capability and role in setting, implementing,
and monitoring standards for obtaining permits to open
private practices and for ongoing certification to ensure the
provision of quality services by PMWs.
ª Establish UPMA as a center of excellence for in-service train￾ing of midwifery and reproductive, maternal, and infant health
services.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Highlights of SEATS II/MAPS
ª Training of 145 members and seven trainers in business
management and community mobilization.
ª Formation or improvement of 172 SDPs.
ª Increase in number of clients served (10–20 percent
monthly increase at trained midwives’ SDPs).
ª Development and piloting of business management and
community mobilization curricula.
ª Follow-up supervisory visits for 143 UPMA members.
ª PMWs linked with DISH training—37 PMWs received RHC
training from DISH.*
ª Provision of CQI training and initiation of quality teams in
selected sites.
ª Development of Board of Directors.
ª Leadership training for UPMA managers.
* DISH offers a six-week comprehensive RHC training program to
 clinicians.
53
ª Significantly enhance the financial
self-sufficiency of UPMA by increas￾ing active membership; acquiring and
successfully operating a private
UPMA clinic and training site; and
acquiring an endowment from
USAID/Uganda.
ª Improve UPMA’s management
capacity, including its capability to
monitor and control costs and to
efficiently and effectively manage an
endowment income.
ª Develop linkages between UPMA
and other midwifery associations—
through the MAPS Africa Regional
activities and the ACNM—to gain
exposure to innovative approaches
for improving quality and sustaining
services and to market UPMA’s
resources to regional associations and
PMWs.
As a result of this assistance, UPMA has
made significant progress in strengthening its
organizational capacity and its efforts to
meet the needs of PMWs.
SEATS I (1991–1994)
During the first SEATS/UPMA collaboration, emphasis was placed on
training and equipping 137 midwives in FP, with nearly 300 midwives
receiving training in social marketing of contraceptives by SOMARC.
In addition, 60 midwives received basic training in business manage￾ment. Thirty-five regional representatives received training in manage￾ment supervision, including the development of skills and facility
checklists. Efforts were also directed at providing office space, furnish￾ings, and equipment with the intent of assisting UPMA in capacity
building. A Board of Directors for UPMA was established, and job
descriptions were developed.
SEATS II/MAPS I (1995–1997)
The overall goal of this phase of technical assistance was to continue to
strengthen UPMA’s capability, with a focus on sustainability. The
process included developing training capability and addressing mem￾ber issues that emerged from the needs assessment. Two curricula—on
SEATS’
lessons learned from
MAPS I n i t i a t i v e 54
Sustainability
ª Ensured financial management
system.
ª Ensured leveraging of activities.
ª Developed and implemented
sustainability plan.
ª Developed and opened model
clinic.
Capacity Building
ª Put in place and computerized
financial and management
systems.
ª Held TOT.
ª Computerized member database.
Collaboration
ª Hosted study tour for midwives
from Senegal and Zimbabwe.
ª Trainers shared expertise with
the Zimbabwe Nurses Associa￾tion (ZINA).
ª Hosted study tour with midwives
from Zambia.
Quality
ª Provided CQI training.
ª Ensured quality teams are
functioning.
ª Developed certification stan￾dards.
Access
ª Realized increase in members
providing quality FP.
ª More than 50 aspiring private
midwives assisted in opening
SDPs.
Training
ª Expanded business management
skill training to some branches.
ª Linked private midwives to
DISH training.
ª Developed training center and
RHC modules for continuing
education.
SEATS II/MAPS II Activities
business management and community mobilization—were developed
and pilot-tested. A TOT was held for seven trainers, and additional
training was provided to 145 UPMA members.
In 1996, UPMA built a small office building through donations from its
members and a grant from the Banker Williams Foundation. UPMA
headquarters was established as a subdistributor for socially marketed
FP commodities (oral contraceptives, condoms, and Depo-Provera),
which is a source of income for the association and ensures supply for
the members. UPMA also obtains free family planning commodities
from the MOH and distributes them to its members.
SEATS II/MAPS II (1998–99)
The goal of the most recent MAPS/
UPMA project was to expand and
sustain UPMA’s role in increasing
access to high-quality FP/RHC services
provided by private-sector midwives in
Uganda (see chart of activities). An
ACNM advisor was seconded to
Uganda to help with the process of
locating, purchasing, and renovating a
building to be used as a model clinic
and training site. This 24-hour clinic,
owned and managed by UPMA,
opened in mid-1999. It offers full-scope
reproductive health services as well
and curative and general inpatient and
outpatient services.
UPMA is a well-established and mature
association. Therefore, the technical
assistance was geared to moving the
organization toward sustainability as
well as national and international
visibility. During MAPS II, UPMA built
a new clinic training center and reno￾vated headquarters, developed and
implemented a financial system, in￾creased its training capability, and
trained over 150 midwives. In addition,
UPMA has been very instrumental in
strengthening the networking among
key midwifery associations in Africa.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Highlights of SEATS II/MAPS II TS II/MAPS II
ª Uganda Study Tour (detailed in body of paper) conducted.
ª Model clinic developed and opened.
ª A total of 83 aspiring private midwives were identified. Of
the 79 who were followed up with, 77 had received some sort
of assistance, 48 had opened a practice and 25 were close to
opening a practice by early 2000. SEATS provided them with
business management/community mobilization training and
delivery kits.
ª Four trainers trained in DISH RHC services, and 51
midwives received RHC training.
ª Training in business management and community mobiliza￾tion provided by UPMA trainers to 38 midwives in Zimba￾bwe.
ª CQI training provided and quality teams initiated in selected
sites.
ª Standards developed.
ª CE training center developed.
ª Four FP/RHC CE modules developed.
ª UPMA funding base diversified by expanding the number of
donors and increasing income-generating activities.
ª Membership database computerized.
ª Computerized financial management developed that
allowed UPMA to receive direct funding from SEATS.
ª UPMA membership increased by 14 percent.
55
UPMA hosted the ICM Symposium in 1995
and collaborates on a regular basis with
ACNM, the Family Planning Association of
Uganda, MOH, the World Health Organiza￾tion, the Cambodian Midwives Association,
and others.
Leveraging
UPMA leaders and members share a tremen￾dous spirit and sense of commitment. The
association has demonstrated a strength and
tenacity to persevere and to hold its mem￾bers together under the most difficult of
conditions. At the same time, the long-term
sustainability of the association is dependent
on its ability to develop a stronger financial
base. It has been almost completely reliant
on donor assistance, supplemented by
membership fees. Becoming more self￾sufficient enables the organization to con￾tinue developing and maintaining programs
and activities that ensure quality FP/RHC
services and makes them more attractive for
assistance such as endowments and long￾term financing or loans.
UPMA has been successful in expanding its
base of support. United Nations Population
Fund (UNFPA) has approved funding (over
$100,000) for a two-year UPMA project to train midwives in life-saving
skills and has completed a UPMA project ($60,000) to train midwives in
LSS. CMS is also supporting two ongoing UPMA activities: 1) develop￾ing and implementing marketing strategies for the UPMA clinic for
$20,000 and 2) funding the Executive Director of UPMA for $24,000. A
smaller project (about $14,000), funded by Family Care International,
will support sensitization and training of UPMA midwives in adolescent
health care services. In addition, proposals have been submitted to
WHO and the International Planned Parenthood Federation for projects
focusing on Safe Motherhood activities. WHO ($1,631) and the Minis￾try of Health/World Bank ($3,308) have completed activities with UPMA
focusing on IEC campaigns and training midwives in STI management
and counseling, respectively.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
.
Dates: October 1997–April 1999
Cost: $112,590 (excluding technical assistance costs)
Major Components:
ª Strengthen and coordinate pre-service and in￾service training through ZNA.
ª Train 35 midwives at Lusaka municipal clinics in
youth-friendly services.
ª Link ZNA with nurse/midwifery associations in
the region.
ª Strengthen the capacity of ZNA.
Improve quality service provision by midwives through:
ª Competency-based training (including TOT).
ª Follow-up and monitoring.
ª Continuing education through the professional
association.
ª Increased access to services.
ª Integration of services.
Key Population:
ª Youth of Zambia
56
UPMA’s Future
The future is very promising for UPMA. Plans include exploring ways
to increase access to capital for opening and expanding private clinics;
expanding and marketing training capability; franchising the model
clinic; improving the availability of affordable equipment and supplies
to members; and, by diversifying funding sources, decreasing donor
dependence. These are ambitious objectives, but UPMA has demon￾strated its determination and capability to succeed.
ZAMBIA
The devastating impact of the AIDS epidemic and high
rates of unsafe abortion among young women were
among the reasons the City Council of Lusaka decided
to take action. In 1996, it developed an action plan to
provide improved reproductive health information and
services to youth in all its health facilities. The MAPS
subproject in Zambia followed this lead in its focus on
youth. The Zambia subproject represented the integra￾tion of three SEATS Special Initiatives: Urban, Youth,
and MAPS. Implemented by Zambia Nurses Associa￾tion (ZNA) and the Lusaka District Health Management
Team, this subproject targeted nurses and midwives in
the public and private sectors, in part by building the
capacity of the ZNA.
ZNA draws its members from government, private,
mission, mines, and defense force health services. Its
mission is to promote and protect the interest of nurses
and midwives, advocating the highest levels of profes￾sionalism and integrity in the delivery of health care
services to the community. Assisted originally by the
Norwegian Nurses Association, and with Norwegian
funding, an office was purchased and equipped.
The goal of MAPS/ZNA collaboration was to
“strengthen the capacity of ZNA in order to ensure the
provision of quality sustainable FP/RHC services to
youth.” This represented a somewhat different focus
than other MAPS subprojects. The objectives of this
subproject were to:
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Highlights
ª Capacity building and strengthening of the association.
ª Computerization of member database.
ª Development of training modules in youth-friendly services.
ª Updates on the topic of FP/RHC for youth (reaching more
than 500 nurse-midwives) provided by ZNA facilitators.
ª Training in leveraging of funds and proposal writing.
ª Revival of the association’s newsletter.
ª Participation in regional quality workshop.
ª Study tours to Zimbabwe and Uganda.
ª Participation in regional workshop on private practice for
nurse midwives and regional dissemination conference.
57
1. Increase youth knowledge of repro￾ductive health and sexuality.
2. Train staff in youth-friendly approaches
to quality care.
3. Promote nurses’ and midwives’ in￾volvement in STI/HIV prevention for
youth at the community level.
4. Provide regional workshops for associa￾tion leadership focusing on the potential
role of private nurse-midwife service
providers in Zambia.
Through MAPS, three continuing education
programs on youth-friendly integrated RHC
were provided to ZNA members. MAPS also
adapted the national reproductive health
curriculum to include youth-friendly ap￾proaches. A TOT workshop for facilitators
was conducted for ZNA members (more than
half of ZNA branches were represented at the workshop) to sensitize
health providers, not only to elements of quality services for youth and
specific counseling interventions, but also to society’s behavior and atti￾tudes toward youth seeking RHC.
A needs assessment (N=172) identified that over 90
percent of the membership required continuing educa￾tion and wanted a newsletter. Another frequently men￾tioned need was for access to new information. The
MAPS continuing education program included develop￾ment of training modules, identification of nurses and
midwives who could provide update sessions, and
competency-based training of nurse-midwives represent￾ing 21 of 42 active branches nationwide. The topics
covered in the continuing education training included
counseling interventions for youth, characteristics of
youth-friendly services, contraceptive methods including
emergency contraception, STI/HIV/AIDS and other
reproductive health issues of significant interest to youth,
and facilitation skills. By June 1999, 11 of 14 member
SDPs that were followed up with site visits reported
youth-friendly actions such as establishing a youth corner
within their clinics to make the services more appealing.
Youth reported using the youth-friendly clinics for a
variety of RHC concerns.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
 Youth Served
ª At one model clinic, the
number of young people
coming for FP and antenatal
care increased approximately
300 percent between 1996
and 1999.
ª 929 new contraceptive users
were reported from two clinics.
58
ZNA’s future objectives include continuing with its membership drive;
becoming a union for nurses; writing a strategic plan; developing a
proposal for developing an association-owned clinic to market to
donors; and becoming a strong, self-sustaining professional body by
the year 2004.
Youth-friendly Services
Characteristics of youth-friendly services as implemented in Zambia
included:
ª Provide youth with reproductive health education
and counseling.
ª Offer appropriate contraceptives to youth.
ª Provide education on STI and HIV prevention.
ª Provide education and services related to safe motherhood.
ª Offer postabortion care and counseling.
In March 1999, association members in four locations in Zambia met
with youth leaders and peer educators. These meetings were held to
give participants a chance to exchange views and encourage the
nurses and midwives to offer youth-friendly information and services at
their SDPs. Society’s behavior and attitudes toward youth seeking
RHC were reviewed and discussed.
Constraints in Zambia
The duration of the MAPS project in Zambia was short. Current MOH
reforms have placed a ban on new training, yet all the current facilities
require continuing support. To continue the programs, facilitators will
need to network with NGOs such as CARE International and others
that provide youth services. ZNA will have to maintain its support in
order to address implementation needs. It will need to:
ª Increase its membership.
ª Improve revenue collection measures.
ª Maintain regular communication and updates on activities
of the association.
ª Provide up-to-date reference material for facilitators.
ª Ensure that health providers assigned to the youth-friendly
services are adequately trained.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Dates: January 1997–July 1999
Cost: $149,060 (excluding technical assistance costs)
Major Components:
ª Strengthen the FP/RHC service provision capability and
sustainability of private nurse and midwife practitioners by
creating a more enabling environment for their practice.
ª Increase the number of private nurse/midwife practitioners
providing FP/STI services.
ª Improve the quality of FP/STI services rendered by private
nurses and midwives.
Key Population:
ª Men and women of reproductive age residing primarily in
Harare or Bulawayo (women of reproductive age number
407,326 in Harare and 173,840 in Bulawayo).
59
ª Ensure consistent support from clinic managers for youth￾friendly services.
ª Improve the commitment of ZNA members.
ª Confront apathy and heavy workloads that prevent youth￾friendly services from being fully implemented.
ZIMBABWE
In 1988, the total fertility rate in Zimbabwe was 5.5 births per woman,
but declined to 4.2 in 1994. By 1994, about
42 percent of Zimbabwean women of
reproductive age were using some form of
modern contraception. This contraceptive
prevalence rate is now estimated at 60
percent (ZNFPC 1999) and is one of the
highest in the sub-Saharan region. Despite
this improvement, 15 percent of married
women have an unmet need for family
planning, and this percentage is almost
double in rural areas and for the illiterate and
semi-literate. Approximately 12 percent of
family planning services are provided
through the private sector, which includes
private nurse/midwives, pharmacists, physi￾cians, and industries (PROFIT 1996). HIV/
AIDS has reached crisis proportions in
Zimbabwe. With an estimated 25 percent of
the population infected, Zimbabwe is the
second most AIDS-affected country in the
world. This crisis has strained national health
resources, making the need to expand the
private sector role in FP/RHC even more
urgent.
In 1996, two studies were conducted in Zimbabwe. The Promoting
Financial Investments and Transfers Project (PROFIT) studied the
private sector’s contribution to FP services in Zimbabwe (and found
that private midwives were a significantly underutilized resource). In
addition, MAPS studied private-practice nurses and midwives to learn
more about their roles, the services they provided, and the factors that
facilitated and/or constrained their ability to practice effectively. The
outcomes of these studies led to the development of a two-year MAPS
subproject in Zimbabwe.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Highlights
MAPS/ZINA planned to assist 50 midwives. However, the project
actually accomplished the following:
ª 109 midwives received assistance through training and/or other
support.
ª 54 aspiring midwives opened their practice sites during the project.
ª 41 new aspiring midwives are set to open practices.
ª 27 additional midwives have taken beginning steps to open a service
delivery point.
ª The number of private midwives grew from 6 in January 1996 to over
200 practicing midwives by July 1999.
ª ICO grew from 6 members in March 1996 to 186 in April 1999.
ª In September 1996, the 22 midwives identified were working in the
two largest cities, Bulawayo and Harare; by 1999, 85 percent of the
200 private midwives served by ZINA/MAPS worked in rural, high￾density areas in all ten of Zimbabwe’s provinces.
ª 38 midwives received training in business management and community
mobilization.
ª The Handbook for Aspiring Private Midwives was produced and
distributed.
ª The Model Clinics Consortium was created to provide intense TA in
the CQI process and application for improving the clinics’ services and
management.
ª A position paper on the current status of nurses and midwives in
private practice in Zimbabwe was produced.
ª Members of ICO now serve on policy-making committees.
ª The member database was computerized.
ª 85 percent of private midwives now meet national FP standards
compared to 10 percent in 1996.
60
MAPS partners in Zimbabwe were the Zimbabwe Nurses Association
(ZINA) and the Independent Clinics Organization (ICO). ICO is a
special-interest organization that had recently been created under the
umbrella of ZINA to provide a forum for the special needs of PMWs.
SEATS’
lessons learned from
MAPS I n i t i a t i v e 61
The overall goal of the MAPS project in Zimbabwe
was to improve access to quality FP/RHC services in
Zimbabwe by expanding the role and number of
midwife practitioners in the private sector. The
objectives were to:
ª Strengthen the FP/RHC service provision
capability and sustainability of private mid￾wife practitioners by creating a more en￾abling environment for their practice.
ª Increase the number of private midwife
practitioners providing FP/STI services.
ª Improve the quality of FP/STI services ren￾dered by PMWs.
Based on the results of the needs assessments, MAPS elected to
provide:
ª Training in family planning, community mobilization,
and business management.
ª Assistance in selecting model clinics.
ª Assistance in developing the corps of aspiring
private midwives.
In 1996, aspiring private midwives were found to have the following
characteristics as identified in the Special Study. They:
ª Are members of ZINA, but not the Zimbabwe Midwives
Group (ZMG) or ICO.
ª Have 10–14 years of experience in the public sector.
ª Are between the ages of 30 and 49.
ª Received basic FP training before 1992.
ª Have had no business management training.
ª Were motivated to open their own clinics by the
challenge, the opportunity for independence and financial
gain, and frustration with their current employment.
Although the ZINA midwives faced many constraints, the service
statistics reported remained fairly steady after a dramatic increase at
the beginning of the project—despite policy barriers such as the prohi￾bition to dispense commodities (see figure above).
SEATS’
lessons learned from
MAPS I n i t i a t i v e
In addition to its focus on quality reproductive health care for clients
within a community setting, ICO regularly provides continuing educa￾tion updates for its members to ensure updated clinical skills. Priority
areas for continuing education (as identified by ICO members) in￾cluded competency-based FP skills development, STI/HIV counseling,
community mobilization, CQI, and business management skills.
A major activity for ZINA was developing a database of midwives and
their training needs. PROFIT and SEATS collaborated to provide
funding for training, purchase of equipment, and development of a
model clinic. Population Services International (PSI) and the Zimba￾bwe National Family Planning Council (ZNFPC) funded four-week
training courses covering basic FP/STI for PMWs who had not had
such training and one-week refresher courses for PMWs who had
received the basic program.
Assistance to Other Midwifery Associations
Several midwifery associations that had learned of the MAPS Initiative
requested technical assistance. While MAPS was unable to respond to
each request, staff assisted whenever possible. Below are some
examples of the type of assistance provided.
CAMBODIA
Cambodia suffered two decades of war, which devastated the national
infrastructure and the national health system—especially for maternal
and child health care. The hazards of motherhood in Cambodia were
described as “disastrous” by several international NGOs. Through
USAID/Cambodia’s Reproductive and Child Health Alliance Program,
jointly implemented by SEATS, AVSC International, and the BASICS
Project, SEATS supported the National Maternal-Child Health Center of
the MOH to conduct a situation analysis on safe motherhood in 1997.
The analysis was designed to identify significant needs, resources, and
gaps in addressing unmet needs related to safe motherhood. Based on
the results, the National Safe Motherhood Policy, Strategies, and Five￾Year Plan of Action were developed, also with SEATS’ assistance.
Major needs identified in the safe motherhood situation analysis included:
ª Protocols outlining clinical management of common
obstetrical and neonatal conditions.
ª Training for midwives in life-saving skills.
62
SEATS’
lessons learned from
MAPS I n i t i a t i v e 63
Although midwives are usually a woman’s first contact with the health
care system in Cambodia, most midwives lacked the skills needed to
provide high-quality RHC. In June 1998, SEATS provided a consultant
to assist in planning and developing a strategy for providing life-saving
skills training in Pursat Province.
The Cambodian Midwives Association (CMA) was organized in 1993
with support from Save the Children Fund (United Kingdom) and CARE
International. In 1994, it was officially accredited as a professional
organization in Cambodia and received funds from USAID. Most of
CMA’s 2,200 members are government employees, although some are
from the private sector or work with NGOs. CMA has 19 branch
offices and owns a private clinic. The goal of CMA is to strengthen its
members’ capacity, knowledge, and skills and improve the morale of
midwives to decrease the country’s maternal mortality ratio and
provide RHC services to Cambodian women. CMA activities are
primarily geared to safe motherhood initiatives and include
breastfeeding assistance, birth spacing, and “baby-friendly” activities.
CMA is eager to participate in MAPS project activities, and communi￾cation with CMA has been geared to building an effective working
relationship with the association and providing opportunities for CMA
members to network with midwives in other MAPS project areas.
SEATS Project funds were used to send members of CMA to the June
1999 MAPS Dissemination Conference and Regional Workshop held
in Harare.
ERITREA
The Government of Eritrea has placed a major priority on improving
primary health care services by increasing access to, demand for, and
availability and quality of integrated health services. SEATS, as a key
partner in the USAID/MOH bilateral Eritrean Health and Population
Project, is supporting FP/RHC activities in three early intervention
zones, covering 60 percent of the population.
Eritrea’s integrated approach called for a comprehensive review of the
RHC challenges facing Eritrean women. The total fertility rate in Eritrea
is 6.1 and the maternal mortality ratio, at 998/100,000 live births, is
one of the highest in Africa. Fifty percent of women receive no antena￾tal care during pregnancy and 82 percent of births take place in the
home. Female genital cutting is nearly universal in Eritrea (95 percent),
and a high number of women report problems or medical complica￾tions with the procedure (Demographic and Health Survey 1995).
SEATS’
lessons learned from
MAPS I n i t i a t i v e
SEATS, through its partner ACNM, supported CQI training and midwife
training in life-saving skills through collaboration with the MotherCare
Project. MAPS provided technical assistance to Eritrean midwives in a
variety of settings. Its activities in Eritrea were geared toward:
ª Facilitating networking between nursing/midwifery
associations.
ª Linking public-sector midwives and their communities.
ª Assisting midwives in improving the quality of care.
ª Assisting midwives in resolving concerns with the Eritrean
national nurses association.
ª Reducing provider risk from HIV/AIDS.
Three Eritrean midwives participated in a MAPS eight-day Study Tour to
Zimbabwe in 1997 to attend the African Midwives Research Confer￾ence. The tour provided the midwives with an opportunity to share
experiences and mutual problems with midwives from other African
nations. Study tour activities included visits to a midwifery training
school, a tertiary referral hospital, and public-sector FP clinics.
After the study tour, the Eritrean midwives developed a six-month
action plan, which they successfully implemented. The plan included
the following activities:
ª Share knowledge and experiences gained from the study tour
with the Director General of Health Services, leaders of the
Nurses Association of Eritrea, and the director and staff of the
hospital on the study tour.
ª Introduce FP counseling to the maternity ward.
ª Introduce FP services to the postabortion and delivery clients.
ª Maintain records of FP services provided.
MAPS’ efforts were circumscribed due to two issues—a border dispute
with Ethiopia during the MAPS timeline, and the acquisition of Eritrea’s
nascent midwifery association by the nurses’ association. However,
MAPS was able to support the introduction of a referral system for FP
clients and organize the study tour. Also, its regional technical advisor
provided technical assistance to the Eritrea SEATS Project and the
Government of Eritrea in conducting an LSS needs assessment. As a
result, SEATS could provide LSS training for 57 midwives, LSS TOT, CQI
training, and provision of equipment for SDPs.
64
SEATS’
lessons learned from
MAPS I n i t i a t i v e 65
TANZANIA
The Tanzania Midwives Association (TAMA) was established in 1992
by a group of midwives registered with the Nurses and Midwives
Council. TAMA started out with 100 midwives and has grown in less
than seven years to 1,100 active members. This growth is a testimony
to midwives’ desire to improve their professional knowledge and
skills—while strengthening their capacity as a group to provide services
to members. TAMA has been working with CARE to promote private
practice for midwives in Tanzania, and TAMA members visited Uganda
to learn how to develop private midwifery practices.
At TAMA’s request, MAPS staff visited Tanzania several times to work
on developing a project, and funded several TAMA members’ partici￾pation in the MAPS Dissemination Conference and Regional Work￾shop held in Harare June 1999. CARE was actively involved with
TAMA at the time and willing to collaborate with MAPS. Although
USAID expressed a desire to assist, the Mission was unable to secure
field support money for the project. However, MAPS advocated for,
and the Mission provided, direct funding to support business manage￾ment training for TAMA.
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Appendix 2
R) ecommendation Suggested Implementer(s
Identify specific laws and policies for nurse/midwives in private
practice in Zimbabwe.
Department of Nursing of the Ministry of Health
(MOH), Zimbabwe Nurses Association (ZINA)
Complete functions, standards, and qualifications for practice.
Conduct pre-service and in-service education based on functions,
standards, and qualifications.
ZINA
Develop regulations based on standards of Health Professions
Council.
MOH, University of Zimbabwe's Departments of Nursing
Science and Medicine, ZINA, Zimbabwe National Family
Planning Council (ZNFPC) Health Professions Council
DA evelop supervisory team. ZIN
Negotiate for increased fees for private FP services. PROFIT, ZINA, ZNFPC
Explore credit and savings program for members. SEATS, ZINA
Develop MIS capability for service data. Independent Clinics Organization (ICO), ZINA,
Zimbabwe Midwives Group (ZMG)
Promote awareness of ZMG and ICO. ICO, ZINA, ZMG
Develop roster of potential covering doctors and guide for coverage
rates.
College of Primary Health Care (PHC), Physicians,
Gynecological Association, PROFIT, ZINA, Zimbabwe
Medical Association (ZIMA)
Implement group purchasing for equipment, educational materials,
supplies, and commodities. ZINA
Explore possibility of a loan fund for start-up or expansion of
private practices. SEATS, PROFIT, ZINA
Conduct workshops to provide current information about private
practice and opportunities for mutual problem solving. ICO, SEATS, ZINA, ZMG
Develop guidelines for aspiring practitioners. SEATS, ZINA
Provide training for FP/STI/HIV to selected practitioners. City Health-Harare/Bulawayo, MOH, SEATS, ZNFPC
Explore feasibility of distance learning program for FP/STI/HIV
training. PROFIT, SEATS, ZNFPC
Network internationally with nurse/midwife associations who are
addressing private practitioner issues. SEATS, ZINA, WHO
PS rovide business management skills training. SEAT
CG ontinue collaborative meetings to share information, support, etc. ICO, ZM
Increase access and distribution of IEC materials and updated
professional literature. SEATS, ZINA
Special Study Recommendations
67
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Appendix 3
Uganda Study Tour Action Plan
Each midwife who participated in the study tour to Uganda developed
a quality improvement action plan to be implemented at her clinic.
This is an example of an action plan.
69
Increased access to care
to respond to a decrease
in clients due to limited
hours.
Expansion of facility to
improve privacy and
provide day care for
working mothers in
community.
Extend evening hours,
providing services up to
8 p.m., six days per
week.
Opened a fixed account
to increase income.
Installed a ceiling.
Added doors to most
rooms.
Reduced waiting time.
Earlier referral to hospital.
Number of clients
increased by 10 percent
per month.
Increase in number of
clients verbally reporting
satisfaction with hours.
Increase in number of
referrals by satisfied
clients.
Improved visual and
audio privacy for all
clients.
Plan for expanding
facility.
Budget for expansion of
facility.
 Needed Action Steps Results
UPMA Midwives Study Tour
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Appendix 4
Criteria for Selection of Model Clinics Criteria for Selection of Model Clinics
1. Inspected and approved by the Health Professions Council
(HPC), according to Statute Instrument 132 (1995), and
possesses a current certificate of registration with the HPC as
a nurse/midwife.
2. Owned and managed by a nurse/midwife who is currently
registered with the HPC, has been approved for private
practice by the HPC and the local authorities, and is a mem￾ber in good standing with the Zimbabwe Nurses Association
(ZINA) or agrees to join/renew membership within three
months.
3. The nurse/midwife owner works in the clinic full time (prefer￾ably as a practitioner, as well as an administrator). The nurse/
midwife has been in private practice for at least six months.
4. The owner is willing and interested in having her facility
become a model clinic (“Best Practices”) site. The practice
has an established relationship with a covering physician for
emergencies, referrals, and consultation.
5. Provides family planning (FP) and sexually transmitted infec￾tions (STI) services or plans to integrate FP/STI services into
care being currently provided.
6. The clinic’s geographical location makes it a logical point for a
model facility, strategically located and with relatively easy
access.
7. Peers recognize the clinic as a “model clinic” in that it has
good facilities, strives to offer quality services, and appears
successful (based upon the growing number of clients).
8. The nurse/midwife is willing to participate in FP/STI and
business management skills training, as deemed appropriate
according to training needs criteria, to upgrade knowledge
and skills.
9. The nurse/midwife is willing to participate in the dissemination
workshop(s) to share and clarify information related to private
practice in Zimbabwe.
71
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Appendix 5
73
Partners in Population: South-to-South Newsletter, Vol.7, June 1999, p. 5
SEATS’
lessons learned from
MAPS I n i t i a t i v e
Appendix 6
ICO Sustainability Action Plan
75
Os bjectives As ctivitie Element
Enhance revenue
base
•n Develop proposal to seek funding for ow
clinic ✓
•s Develop proposal to leverage donor fund ✓
•p Participate in SEATS leveraging worksho ✓
•s Identify funding opportunitie ✓
•w Encourge members to pay dues, recruit ne
members, and revive inactive members ✓
•e Review and revise annual fee structur
•s Submit proposal to donor ✓
• Income
generation
• Leveraging
• Capacity
building
Enhance/improve
private practice
environment
• Develop and submit ICO position paper to
MOH
• Develop pharmaceutical in-service course
• Develop strategies for closer link between
public and private sector
• Improve transparency of PMW to regulatory
bodies and community by having model
clinics
• Seek opportunities to dialogue with policy￾making groups
• Link with University of Zimbabwe graduate
school of Social Work to be a field placement
site for a student
Improve ICO
management
system capability
• Computerize membership database ✓
• Enhance financial mangement capability ✓
• Subcontract a bookkeeper to develop system ✓
• Upgrade financial system to include ICO
clinic accounts
• Develop strategic and business plan for ICO ✓
Expand ICO
membership
services
• Develop strategies for improving
communication among ICO members
• Develop training capability within ICO for
business skills and community mobilization
• Offer pharmaceutical IEC
• Make ICO clinic available as training site
• Offer FP/RHC/HIV management updates at
monthly meetings ✓
• Seek funding for continued FP/HIV training
for ICO ✓
• Seek access to FP commodities and RH
drugs ✓
Increase ICO
capacity in
assisting members
to improve quality
and access of
health services
• Develop private practice standards
• Develop training capability within ICO for
business skills and community mobilization
• Offer pharmaceutical IEC
• Make ICO clinic available as training site
• Offer FP/RHC/HIV management updates at
monthly meetings ✓
• Seek funding for continued FP/HIV training
for ICO ✓
• Seek access to FP commoditites and RH
drugs ✓
• Commodity
procurement
• Training
• Quality
improvement
American College of Nurse-Midwives (ACNM)
818 Connecticut Ave., NW, Suite 900
Washington, DC 20006
Tel (202) 728-9860
Fax (202) 728-9897
Internet: <info@acnm.org>
www.acnm.org
JSI/Boston
44 Farnsworth Street
Boston, MA 02111-1211
U.S.A.
Tel. (617) 482-9485
Fax (617) 482-0617
Internet: www.jsi.com
JSI/Washington
1616 N. Fort Myer Dr., 11th Floor
Arlington, VA 22209-3100
U.S.A.
Tel. (703) 528-7474
Fax (703) 528-7480
Internet: seats_project@jsi.com
www.seats.jsi.com
USAID Contract CCP-C-00-94-00004-10
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