The Ministry of Public Health, supported by the GAVI Alliance, has developed its stewardship role at the district-level by putting in place 152 District Public Health Officers (DPHOs). HPRO was contracted to independently evaluate the pilot project to help inform MoPH's future policy decisions regarding the programme.

To estimate retention of and need for qualified midwives in public sector facilities through assessing the retention rates, need for midwives, and factors associated with leaving or continuing employment in the public sector.

This cross sectional evaluation was conducted in three components between October 2011 and April 2012, with utilization of qualitative and quantitative methods. Eleven provinces of diverse geographic distribution, donor coverage, and security status were directly assessed. Component one included focus group discussions with midwifery students and in-depth Interviews with key informants. Component two included direct assessment of 11 provinces where midwives actively working in the public sector, facility managers, community health workers, and midwives who had left public sector jobs were interviewed. In addition, telephone Interviews were conducted with midwives accessible by telephone in the remaining provinces. Component three included sharing findings of two components with key informants and through a stakeholder meeting in which policy and programming recommendations were developed.

A total of 456 facilities were assessed with direct interviews of 454 facility managers and 570 midwives. The estimated retention rate of CME graduates in any public sector facility is 61.3% (range: 28 – 84%). , while the retention rate at the assigned deployment site is 36.8% (range: 13.3% to 58.9%). Of BPHS facilities evaluated, 20.4% of those with positions for midwives do not have a midwife on staff. These facilities were disproportionately smaller centers (e.g. sub-centers and basic health centers) with correspondingly lower volumes of reproductive health service provision. Retention at the assigned deployment site were 33% less likely for those working in an insecure province (Odds Ratio=0.67, 95% CI: 0.45 – 1.00), while donor coverage was not a significant factor for retention. Key reasons reported for not reporting or leaving public health positions were insecurity (46.4%), family disagreement (28.1%), increased workload without financial compensation (9.9%), and lack of proper housing facilities (7.8%). A total of 182 midwives were reached through telephone of whom, 42.9% were CME graduates. With regard to deployment, 53.0% were working at their assigned clinic; the most common reasons for leaving or not reporting for duty were insecurity (36.5%), family disapproval (34.6%), got married (13.5%), and lack of housing/education for children (13.5%). In questionnaires and in-depth interviews and stakeholders’ feedback, all key informants, midwife and facility manager participants identified insecurity, family disapproval, lack of civil service status, poor initial selection practices, lack of career pathways, improper living amenities, lack of schooling for children in rural areas, and inadequate financial compensation as key reasons for midwives leaving public sector positions. There were high levels of consensus between all groups surrounding reasons for midwives leaving their profession and similarity between suggested policy and program responses.