1. 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.

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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