Human Resources and ART Scale-up in Malawi Matt Boxshall, Ralf Weigel, Eustice Mhango, Erik Schouten, Andreas Jahn, Sam Phiri

Human Resources Crisis MMR 1,000 per 100,000 live births MMR 1,000 per 100,000 live births But routine, protocol driven programs (eg NTP, EPI, ITN) function effectively... But routine, protocol driven programs (eg NTP, EPI, ITN) function effectively...

ARV Scale up Plans 850,000 HIV +ve, 80,000 new infections per annum, 170,000 in need of HAART 850,000 HIV +ve, 80,000 new infections per annum, 170,000 in need of HAART GFATM HAART arrived in Malawi June 2004, 40,000 people had started HAART by end 2005 GFATM HAART arrived in Malawi June 2004, 40,000 people had started HAART by end clinics nationwide starting patients treatment as of April clinics nationwide starting patients treatment as of April year ARV Scale-up Plan, 2010 targets; 5 year ARV Scale-up Plan, 2010 targets; – 245,000 ever started, – 208,000 Alive and On Treatment – 45,000 starting ART per year

Additional Work? Will ART Scale-up mean additional work for the Health Sector? If it does, where will the burden of additional work fall? Patients with AIDS will require clinical care with or without ART. Patients with AIDS will require clinical care with or without ART. As numbers on treatment increase, proportion of new cases decreases As numbers on treatment increase, proportion of new cases decreases Focus on routine ARV reviews! Focus on routine ARV reviews! In Malawi, these reviews are carried out by Nurses In Malawi, these reviews are carried out by Nurses

ART Clinic Nursing Station Workload All patients are first seen by a nurse at each visit All patients are first seen by a nurse at each visit Review includes screening for OIs & reactions, discussing adherence, capturing data, dispensing drugs Review includes screening for OIs & reactions, discussing adherence, capturing data, dispensing drugs Three rooms see 180 visits per day, 60 per room, just over 5 minutes per review. Three rooms see 180 visits per day, 60 per room, just over 5 minutes per review. Half our patients come monthly, half every two months. Approximately 1/3 patients are currently referred on to clinicians Half our patients come monthly, half every two months. Approximately 1/3 patients are currently referred on to clinicians We employ 5 or 6 nurses to ensure the rooms are fully operational ; we should plan for 2 nurses for every thousand people on treatment. We employ 5 or 6 nurses to ensure the rooms are fully operational ; we should plan for 2 nurses for every thousand people on treatment. 200,000 patients on ART will require very approximately 400 nurses, FTE 200,000 patients on ART will require very approximately 400 nurses, FTE

Options Reducing targets is NOT an option 1. Continue as we are – nurse led reviews 2. Reduce the time per nurse review 3. Reduce the frequency of review 4. Shift burden of reviews to other cadres

HSA ARV Officers? TB program is the paradigm TB program is the paradigm Specialist vs Generalist Specialist vs Generalist Program integration Program integration Professional boundaries – nurse roles Professional boundaries – nurse roles Decision making – limits of protocol Decision making – limits of protocol Supervision Supervision

Conclusions & Thanks