Human Resources for HIV Scale Up

in Malawi Vienna, 2010

Frank M Chimbwandira, S Makombe, E Mhango, J Njala, L Tenthani, P Moses, E Schouten, Z Chirwa, A Jahn

Malawi Indicators• 13.06 million people• 12 % HIV prevalence

• among 15-49 year olds

• About 1 million PLWH• 384 000 in need of ART

– 211 246 PLHIV alive and on ART by March, 2010

• Approx. 700 000 orphans due to AIDS epidemic

• 1 Physician : 49 000 people• 1 Nurse :1 800 people

Human Resources for Health IMalawi situation in 2004:• 64% vacancies among nurses;

– Over half of 29 districts have less than 1.5 nurses per facility, and five districts have less than one

•53% vacancies among clinical officers; •85%-100% vacancies among specialists– 10 districts without a MoH doctor, four districts

without any doctor at all

Human Resources for Health II

• In 2004 Dr Peter Piot (UNAIDS) and Dr Suma Chakrabarti (DFID) were concerned

“ ….. that without a substantial increase in health

workers, it would not be possible [for Malawi] to roll out antiretroviral treatment without further undermining the already weak health system.”

Palmer D, ………

Reproductive Health Matters 2006; 14(27):27-39…………

Human Resources for Health III

• Inadequate workforce in the health delivery system was aggravated by – Poor recruitment systems– Limited or non-responsive trainings– Poor staff retention mechanisms – Inadequate finances

Emergency HRP I: Plan

• Drawn up for 2004 – 2010 period• Focused on retention, deployment,

recruitment, training and tutor incentives• Targeted 11 cadres

– Physicians, nurses, COs, MAs, pharmacists, lab technicians, … and expansion of community health worker cadres

• Budget: ~US$200 m US$270 m– GoM, DFID, GFATM, Health SWAp ……

Emergency HRP II: Approaches• Short-term interventions

– Recruit unemployed or retired staff– Expatriate staff for TA and mentoring– Salary top-ups– Recruitment of community health workers

• Long-term interventions– In-country pre-service training– Comprehensive Monitoring and Evaluation

Systems

Emergency HRP III: Outcomes I

• More posts were filled between 2003 and 2007– 30% increase in nurses, 40% in medical

doctors, and 50% in clinical officers• Reduced emigration of nurses• Over 5600 community health workers

were recruited• Training institutions created more room

for enrollment: infrastructure development

Emergency HRP IV: Outcomes II

-

50

100

150

200

250

2003 2004 2005 2006 2007 2008 2009

Relative change in MOH and CHAM staffing for5 main cadres in Malawi from 2003 to 2009 (2003=100)

Clinical Officer

Nurse

Medical Assistant

Laboratory Technician

Physician

Some Cadres and TasksCadre Counseling HIV

Testing Clinical Staging

ARV Drug Initiation

Follow up

“Non-health workers” +++

Health Surveillance Assistants

+++ +++ ?

Laboratory Technicians +++

Nurses ++ ++ ++ ++ +++

Medical Assistants + + +++ +++ +++

Clinical Officers + + +++ +++ +++

Medical Doctors + +++ +++ +++

ART Scale Up: Malawi

2006Sites: 141

Alive: 59,980Coverage: 17%

2009Sites : 377

Alive: 198,846Coverage: 53%

2008Sites: 221

Alive: 147,497Coverage: 41%

Doctors and Clinical Officers (COs)

Doctors , Clinical Officers, Medical Assistants (MAs)

Doctors, COs, MAs and Nurses

2007Sites: 163

Alive: 100,649Coverage: 28 %

2004Sites: 24

Alive: 10,761Coverage: 3%

Policy Changes: Who should initiate ART? >………………..

2003Sites: 9Alive: ??

Coverage: ??

ART Sites In Malawi

HIV Testing and Counseling

Year

HIV Testing and Counseling 2009

HTC Scale Up• Approaches

– Door-to-Door HIV testing and Counseling – National HTC Campaigns

• HTC weeks, targeted sites or functions – Mobile and Outreach HTC– Task shifting:

• Health Surveillance Assistants do HTC – Task sharing:

• Provider Initiated Testing and Counseling

Challenges

• Need for more workforce– Increasing number of clients on ART– Implementation of new WHO ART/PMTCT

guide– Task shifting has a limit: HSAs may not

initiate ART nor follow up clients• Central posts need strengthening

– Eg Central Medical Stores & technical posts • Donor-dependence on staff retention:

– TAs, Salary top ups ….

Plans• New Programme of Work/SWAp

– Under discussion with donors, HR still • Decentralise HIV services

– Opening of more clinics – Engage expert patients through support groups– Strengthen Integration of HIV services

• Use of new and better regimens (in ART)– Triomune Atripla from 2011

Conclusions

• HR will determine further scale up of HIV services including implementation of the new adopted WHO ART/PMTCT Guidelines.– Training of more personnel (Physicians,

COs, nurses and MAs) still remains an option for Malawi

• Sustainable retention mechanisms are essential too.