On September 9–11, 2014, the Global Forum on Innovation in Health Professional Education and the Forum on Public–Private Partnerships for Global Health and Safety of the Institute of Medicine convened a workshop on empowering women and strengthening health systems and services through investing in nursing and midwifery enterprise at the Rockefeller Center in Bellagio, Italy. Experts in women’s empowerment, development, health systems’ capacity building, social enterprise and finance, and nursing and midwifery explored the intersections between and among these domains. Innovative and promising models for more sustainable health care delivery that embed women’s empowerment in their missions were examined. Participants also discussed uptake and scale; adaptation, translation, and replication; financing; and collaboration and partnership.
What this report does not address are the precise quality measures of clinical skills and practice that could lead to a successful enterprise. The report also does not focus on specific educational requirements or individual competencies needed for developing entrepreneurial skills and how to identify personality traits of successful entrepreneurs. While these aspects are important for promoting businesses, they were not emphasized at the
________________
1 The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the rapporteurs (with acknowledgment of the assistance of staff as appropriate) as a factual account of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Institute of Medicine. They should not be construed as reflecting any group consensus.
workshop and therefore do not appear in this summary report. Instead, the report highlights examples and explores broad frameworks for existing and potential intersections of different sectors that could lead to better health and well-being of women around the world and how lessons learned from these examples might be applied in the United States.
WORKSHOP OBJECTIVES
Workshop participants came from different countries with unique cultures, histories, and systems of government, finance, education, and health care. This diversity of perspectives enriched the discussions on women’s empowerment and health systems strengthening through investment, innovation, and enterprise in nursing and midwifery. Examples from low- and middle-income countries, where significant developments in nursing and midwifery practices are taking place, were discussed as a means of exploring transferability of innovations from countries with low financial resources to higher-income countries—in particular, the United States. The workshop was designed to illuminate approaches that do and could empower women and strengthen health systems through targeted investments in social entrepreneurship of nurses and midwives (see Box 1-1).
BOX 1-1
Statement of Task
An ad hoc committee under the auspices of the Institute of Medicine will plan a 2-day public workshop that is aimed at exploring, explaining, and informing translation of models and lessons learned relating to innovative investment in nursing and midwifery training and enterprising practices as avenues for empowerment of women and strengthening of community-based health services in lower-income countries. Presentations and discussions will also explore ways in which these models might be advanced globally to better achieve the social mission of the health professions and to explore their relevance and potential application in the United States.
This global workshop, to be held at the Rockefeller Bellagio Center in Italy, will convene experts in the areas of women’s empowerment and development, health systems’ capacity building, social enterprise and finance, and nursing and midwifery. The committee will organize and conduct the workshop, select and invite speakers, and moderate sessions at the workshop. Following the conclusion of the workshop, an individually authored summary of the presentations and discussions will be prepared by a designated rapporteur in accordance with institutional guidelines.
This summary provides a synthesis of the presentations and discussions that took place at the workshop, and should not be construed as a consensus document. All statements are attributed to the individuals who spoke them. It should be further noted that in an effort to create a smoother flow of the statements made at the workshop and captured in this report, not all of the text follows the chronological order in which the discussions took place or appears in the agenda found in Appendix A.
WORKSHOP OVERVIEW2
While nursing and midwifery are different disciplines, they have common characteristics that can provide a platform for service flexibility and responsiveness in health systems. Marla Salmon stated that both disciplines offer capacity for expansion and breadth through generalist roles, or contraction and depth through specialization. In addition, nurses and midwives are often deployed strategically to meet the needs of vulnerable populations in a variety of contexts, as well as for ongoing services to others. Important contributions made by nurses and midwives help communities meet their overall health needs. Such contributions include supporting patients in navigating complex health care systems and working at the interface between communities and public services. Their wide distribution and relatively greater numbers along with their proximity to and engagement with their communities ideally position nurses and midwives to have a significant influence in maintaining the health of the communities they serve (WHO, 2014).
As both public and private sectors seek to find cost-effective solutions to health challenges around the world, nurses and midwives are increasingly called upon to provide an even greater depth and breadth of services. At times, said Salmon, this has resulted in improved access to services for their clients and their communities, as well as increased opportunities for enhancing their own status and well-being through greater autonomy, broadened scopes of practice, and even ownership or operation of their own enterprises.
Categories for nursing and midwifery enterprise include provision of general and specialty direct services as well as indirect care support and coordination services such as scheduling medical procedures, charting patient progress, and providing effective communication between families and social service providers. Customers can range from patients and communities to governments, industries, or other health and nonhealth workers. These enterprises can offer clusters of services—such as primary care,
________________
2 This section summarizes information presented by Marla Salmon, University of Washington (UW).
home health, or women’s health—or single services, such as circumcisions or postabortion care. Additionally, partnerships with other care providers could expand their breadth and reach of services and potentially build a larger and more robust business. Nurses and midwives would benefit from the support and economies of scale offered through these arrangements.
Salmon stated that opportunities for nursing and midwifery enterprise are often associated with provision of services in rural or underserved areas, overlooked or emerging diseases or populations, or in relation to activities not traditionally associated with physicians or other providers (such as maternity or elder care). These areas provide opportunities for entrepreneurship and ownership, particularly in community-based settings. By expanding their traditional scope of services, nurses and midwives could build practices in areas that require strong coordination and collaborative skills; for example, this could include housing-based services for managing the care and support of vulnerable families, pharmacy-based services linking care to medication analysis and delivery, or early childhood-based services for special health care needs. These examples, which broaden the scope of practice while taking advantage of distinctive assets and skills of nurses and midwives, could open new opportunities for unique enterprise.
The convergence of growing investment and innovation in nursing and midwifery enterprise is also creating opportunities for empowerment of women. Both disciplines are female-dominated professions and directly impact the health and well-being of women, Salmon said. Workshop participants discussed the elements of women’s empowerment associated with enterprise, noting that such opportunities are not only for nurses and midwives, but also those they serve and work with, including the community and their organizations. Becoming a nurse or midwife has transformative potential through the opportunities of greater education and training, knowledge and skills acquisition, social and economic mobility, earnings, and political and professional voice. Opportunities associated with enterprise can expand the possibilities for empowerment, including asset acquisition, ownership, and expanded possibilities for leadership and decision making. Empowered nurses and midwives can also provide enabling opportunities for the development of other women, including mentorship, supervision, training, and career progression. Additionally, there is potential for impact through caring, coaching, and connecting to health-related work. They can also serve as inspiration and resources to other women and girls in the community, including inspiring entrance into nursing or midwifery careers and providing informal heath information and care.
How can this potential be realized? Participants brought together the domains of nursing and midwifery and women’s empowerment in discussing innovations and investments for improving health care delivery. As populations grow and age, existing health systems cannot continue to
provide the same level of care to everyone they serve. At the same time, many gaps in coverage continue to exist. While emerging technologies can help expand the reach and reduce cost, capitalizing on lower-cost—but high-quality—workforce elements can also play a role. Embedding women’s empowerment in the ownership or operation of their own enterprise, whether through a traditional delivery method or an innovative one, could be an avenue for a nurse or midwife to have a significant positive effect on health and society.
There is a convergence of forces at work, said Salmon, that make nursing and midwifery particularly critical at this moment in time: overtaxed health systems, growing unmet health needs, recognition of the importance of women’s development to health and societal well-being, growing public- and private-sector engagement, increased investment in the health sector, and expansion of innovative models of service. In addition, within the global context, the health and development agendas are becoming intertwined as countries see the importance of this in order to advance society. She said that organizing and supporting nursing and midwifery enterprise ultimately has the possibility for several gains. Strengthened health systems and health services lead to improved health, and increased women’s well-being and empowerment can lead to gender equity, economic and social well-being, and stronger societies.
LAYOUT OF THE REPORT
The chapters of this report, divided into 3 parts, comprise accounts of the presentations and discussions that took place at the workshop. Speakers whose remarks are noted in the report were identified by the workshop planning committee members, who were instrumental in determining the focus of the workshop.
Part I (Chapter 2 and 3) lays the foundation for understanding the various elements as described by Salmon in her overview of the workshop. More specifically, this section examines the impact targets of nursing and midwifery, which are women’s empowerment (Chapter 2) and strengthening of health systems and services (Chapter 3). The intentionality of women’s empowerment is a theme that resonated throughout these chapters and the entire workshop.
Part II (Chapters 4, 5, 6, and 7) begins with an overview of nursing and midwifery education and enterprises, as well as a section exploring how social business models can be used to empower women (Chapter 4). Chapter 5 includes specific country perspectives on the issues covered in the previous chapters, delving into the issues encountered in Palestine, Nigeria, and the United States. Examples of innovations and strategies used to strengthen health systems and invest in women-owned health enterprises and global
health enterprises are explored in Chapter 6. Chapter 6 also includes the findings of a paper by Carleigh Krubiner, Marla Salmon, and Gina Lagomarsino; the authors used the Center for Health Market Innovations database to identify programs in low- and middle-income countries that address empowering women through nursing and midwifery. Chapter 7 examines social enterprises and how to scale impact, looks at some best practices for investing in health, and discusses investment models, such as franchises, for nursing and midwifery organizations or clinics.
Part III (Chapters 8 and 9) first explores how to transfer the models and lessons learned across national and international boundaries (Chapter 8). Possible challenges and opportunities are outlined, as well as strategies for transferring models globally and to the United States. Lastly, Chapter 9 discusses themes raised throughout the workshop and potential next steps for the way forward.
Appendixes A, B, and C include the agenda for the workshop, the speaker biographies, and the list of workshop participants, respectively. Appendix D is a paper written by speaker Oscar Picazo and colleagues, which describes in more detail four major innovations using nurse and midwife empowerment in the Philippines.
REFERENCE
WHO (World Health Organization). 2014. Global health workforce statistics database: Global health observatory data repository. http://apps.who.int/gho/data/node.main.A1443?lang=en&showonly=HWF (accessed December 22, 2014).
