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 I
Malawi 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
Relative change in MOH and CHAM staffing for
5 main cadres in Malawi from 2003 to 2009 (2003=100)
250
200
150 Clinical
Officer
Nurse
100
Medical
Assistant
50 Laboratory
Technician
Physician
-
2003 2004 2005 2006 2007 2008 2009
Malawi ART Scale Up Plans:
Public Health Approach
2004 -2005 2006-2010 2009-2012
• Open 60 clinics • ……. • …….
• Provide free ARV drugs • Open more clinics • Add pre-ART
• One standard 1st line • Reduce burden services
regimen • Decentralise • Promote pre-
• Standardise training services service trainings
• Set drug procurement • Task shifting:
and distribution system medical assistants
• Set National Monitoring and nurses to
system initiate ART and
• ……. follow up clients
Some Cadres and Tasks
Cadre Counseling HIV Clinical ARV Drug Follow
Testing Staging Initiation up
“Non-health workers” +++
Health Surveillance +++ +++ ?
Assistants
Laboratory Technicians +++
Nurses ++ ++ ++ ++ +++
Medical Assistants + + +++ +++ +++
Clinical Officers + + +++ +++ +++
Medical Doctors + +++ +++ +++
ART Scale Up: Malawi 2009
Sites : 377
Alive: 198,846
Coverage: 53%
2006
Sites: 141
Alive: 59,980
Coverage: 17%
2003
Sites: 9
Alive: ??
Coverage: ?? 2008
2007 Sites: 221
2004 Sites: 163 Alive: 147,497
Sites: 24 Alive: 100,649 Coverage: 41%
Alive: 10,761 Coverage: 28 %
Coverage: 3%
Doctors and Clinical Doctors , Clinical Officers, Doctors, COs, MAs and
Officers (COs) Medical Assistants (MAs) Nurses
Policy Changes: Who should initiate ART? >………………..
ART Sites In Malawi
Cumulative number of public and private ART sites
between 2003 and 2009 in Malawi
350
300
Number of Sites
250
200
150
100
50
0
.2003. .2004. .2005. .2006. .2007. .2008. .2009.
Years
Public Private
HIV Testing and Counseling
Annual figures of HIV Tests carried out in Malawi
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
.2004. .2005. .2006. .2007. .2008. .2009.
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.