Overcoming HRH bottlenecks for ART scale up in Malawi:

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Overcoming HRH bottlenecks for ART scale up in
Malawi

• Mexico City
• 4 August 2008
• Dr Kelita Kamoto
• Head of the HIV/AIDS Unit
• Ministry of Health
• Malawi

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Malawi

• Population 13 million, GDP US200
• Generalised HIV epidemic, 900,000 people
  infected, adult prevalence 12
  
• Health systems severely constrained (e.g. 40 of
  health posts are vacant)
  
• An estimated 120,000 people on treatment (2 of
  adult population)
  
• In 2007 over 900,000 people tested and
  counselled
  
• In 2007 over 25 of HIV infected pregnant women
  receiving ARV prophylaxis

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How to develop a successful programme without
undermining other health services?

• Design of the programme Base the programme on
  realities in the health sector
  
• Address HRH issues Advocate for improving HRH
  improvementsmake optimal use of existing staff
  (task shifting)
  

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Design of the programme

• Based on existing realities and, therefore makes
  optimal use of scarce human resources in the
  health sector
  
• Clinical vs public health model.

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Characteristics of the ART Programme

• Based on realities - a public health approach
• Simple
• Standardised
• Inclusive
• Tasks shifting
• Strong emphasis on monitoring and supervision

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Simple

• Focus on roll out of 1st line regimen, especially
  in initial phase of programme
  
• One regimen for all
• Not dependent on laboratory monitoring or CD4
  count
  
• Simple drug supply management (kit system,
  special packaging, e.g. 120tabs CTX for 2 months
  supply of CPT)
  

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Standardised

• In all sites (public, mission, private sector)
• Case finding
• Treatment regimen
• Training
• Drug resistance monitoring
• Guidelines
• Reporting
• Supervision and monitoring

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Inclusive

• All providers (government, mission, NGO, Private
  for profit) involved in the development of
  protocols, guidelines, scale up plans, ME tools,
  reporting, etc.
• Therefore, a buy in of all providers and ONE
  national system.
  

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Task shifting to staff with less training

• Initiation of ART can be done by non-MD
  clinicians (COs and MAs) and nurses
  
• HIV testing and counselling is done by lay-people
  and health staff with a very short training (3
  months - Health Surveillance Assistants)
  
• Research is ongoing to establish to what extend
  tasks can be shifted. (e.g. study by Lighthouse
  to HSAs taking care for stable patients on ART)

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Supervision and monitoring

• A programme that is based on simplified,
  standardised and tasks carried out by staff with
  minimal training, therefore, need strong
  supervision and monitoring system to maintain the
  quality of the programme.
• Malawi has developed a system of quarterly
  supervisory and monitoring visits with feedback
  on quality of services provided (certificate of
  excellence or letter to improve the service).

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HR needs of the ART programme

• By March 2008, 202 sites (government, mission,
  private sector) 165,000 people ever started
  (110,000 alive and on treatment). This number is
  expected to double in the coming 5 years.
• Need for an increase of health workers for ART
  scale up, but with a Public Health Approach and
  Task Shifting less health workers are needed per
  1,000 people on ART

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Number of health workers for ART
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Do ART services take away staff from other
essential health services?

• In June 2006
• with 43,390 people alive and on ART (59,851
  people ever started)
  
• 916 health worker days per week required to run
  the ART clinics
  
• 257 HCW lives saved is equivalent to 1,139 extra
  staff days in the health sector
  
• (Published in WHO Bulletin)

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Address HRH issuesAbsolute shortage of health
staff

• Situation in 2004
• 64 vacancies among nurses 53 vacancies among
  clinical officers 85-100 vacancies among
  specialists
  
• Over half of 29 districts have less than 1.5
  nurses per facility, and five districts have less
  than one
  
• 10 districts without a MoH doctor, four districts
  without any doctor at all

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Human Resources

• Staff per 100,000 population (WHO, 2004)
• Absolute shortage of health staff in Malawi

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Why?

• Underinvestment in training
• HIV/AIDS, SAP
• HRH not a major theme in the health reform
  movements of the 1980s and 1990s
  
• Poor retention
• Push factors low wages, high workloads, weak
  supervision, inadequate housing, shortages
  supplies, weak and unresponsive HR management
  
• Pull factors international migration and
  domestic dynamics. Growth research jobs, NGOs
  (especially HIV/AIDS jobs, private sector)

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Human Resources

• Global Fund refused human resources component of
  Round 1 grant (funding was substantially
  reduced)
  
• GoM declared a crisis of human resources the
  health sector has collapsed (Secretary for
  Health)
  
• Chakrabarti / Piot (February 2004) the health
  sector human capacity crisis in Malawi is an
  emergency requiring exceptional measures that
  might otherwise be dismissed as
  unsustainableHIV is an advocate for Health
  systems strengthening
• This lead to 6-year Human Resources Emergency
  Relief Plan (US 273 million)
  
• HIV/AIDS as a wedge to HRHS improvements

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Emergency Human Resources Programme
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Emergency Human Resources Programme

• Expand training capacity in the health sector
• Improve retention and re-engagement, salary
  top-ups for 11 key cadres of GoM and CHAM staff,
  recruitment and re-engagement programme, bonding
  initiative, rural location incentives, staff
  housing
• Stop-gap external support for critical posts
  (mostly teaching) - 50 volunteer doctors, nurse
  tutors
  
• HR management support for MoH - 3 TA supporting
  MoH HR function for 2yrs
  
• ME linked to SWAp ME framework

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Conclusions

• A successful scale up of the ART programme in
  Malawi was possible on the basis of a well
  planned scale up of the ART programme that was
  based on realities in the health sector using a
  public health approach and task shifting combined
  with an emergency human resources programme