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 Goodmorning, I would like to present to you the uptake of HIV services, and specifically HTC, PMTCT and ART services.

HIV & AIDS Unit MOH Malawi Population 13 million, GDP US$200 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 HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi 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 improvements make optimal use of existing staff (task shifting) HIV & AIDS Unit MOH Malawi

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. HIV & AIDS Unit MOH Malawi

Characteristics of the ART Programme Based on realities - a public health approach: Simple Standardised Inclusive Tasks shifting Strong emphasis on monitoring and supervision HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi 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) HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi Standardised In all sites (public, mission, private sector) Case finding Treatment regimen Training Drug resistance monitoring Guidelines Reporting Supervision and monitoring HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi Inclusive All providers (government, mission, NGO, Private for profit) involved in the development of protocols, guidelines, scale up plans, M&E tools, reporting, etc. Therefore, a ‘buy in’ of all providers and “ONE” national system. HIV & AIDS Unit MOH Malawi

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) HIV & AIDS Unit MOH Malawi

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). HIV & AIDS Unit MOH Malawi

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 HIV & AIDS Unit MOH Malawi

Number of health workers for ART HIV & AIDS Unit MOH Malawi

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) HIV & AIDS Unit MOH Malawi

Address HRH issues Absolute 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 HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi Human Resources Staff per 100,000 population (WHO, 2004) Absolute shortage of health staff in Malawi Cadre South-Africa Botswana Ghana Zambia Tanzania Malawi Doctors 69.2 28.7 9.0 6.9 2.3 1.1 Nurses 388.0 241.0 64.0 113 36.6 25.5 HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi 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) HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi 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 unsustainable’ HIV 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 HR&HS improvements HIV & AIDS Unit MOH Malawi

Emergency Human Resources Programme The challenge is to ensure that the scale up of human resources, at the very least, keeps pace with the scale up of ART (and other Universal Access scale up of HIV prevention and care). HIV & AIDS Unit MOH Malawi

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 M&E – linked to SWAp M&E framework The challenge is to ensure that the scale up of human resources, at the very least, keeps pace with the scale up of ART (and other Universal Access scale up of HIV prevention and care). HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi 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 HIV & AIDS Unit MOH Malawi