The Health Sector in Malawi Health Policy in Malawi The Government‟s overall goal for the health sector is to establish through a Sector Wide Approach (SWAP) arrangement, an effective and efficient health care delivery system that is responsive to the needs of the people of Malawi, especially the vulnerable groups, the poor, women and children. The Essential Health Package (EHP) The Essential Health Package (EHP) is the primary health strategy for the Ministry of Health. It aims to address the major causes of morbidity and mortality among the general population focusing particularly on medical conditions and service gaps that disproportionately affect the rural poor. Its objectives are to improve technical services and allocate efficiency in the delivery of health care; to ensure universal coverage of health services; and to provide cost-effective interventions that can control the main causes of disease burden in Malawi. The EHP interventions are based on a prioritised but limited approach to health service provision with an integrated delivery strategy that is cost effective using multi-skilled health workers. The Malawi EHP consists broadly of the following eleven intervention areas: Prevention and Treatment of vaccine preventable diseases, Malaria Prevention and Treatment, Reproductive Health Interventions including Safe Motherhood Initiatives, Essential Obstetric Care and PMTCT, Prevention, control and treatment of Tuberculosis and related complications, Prevention and treatment of Schistosomiasis and related complications, Management of Acute Respiratory Infections and related complications, Prevention, treatment and care for Acute Diarrhoeal Diseases (including cholera), Prevention and management of HIV/AIDS, Sexually Transmitted Infections and related complications including VCT and the provision of ARVT, Prevention and management of Malnutrition, Nutrition deficiencies (iodine, Vitamin A, Iron) and related complications, especially those associated with HIV/AIDS, Management of eye, ear and skin infections and related complications, Treatment of common injuries including emergency care for accidents and trauma and their complications The Health Sector Programme of Work (POW) 2004 to 2010 The 6-Year Program of Work (POW) for the period 2004-2010 is effectively the national health plan and provides an implementation strategy for health sector initiatives including the EHP. It is based on the SWAP to health development and the reorganization of the health sector based on the principle of decentralization of health services to District Assemblies. Operational strategies have infrastructural requirements including the provision of drugs, medical supplies and equipment. It also requires the strengthening of management and support systems at the District level. Human resource requirements are to be met through the training of an adequate number of health personnel to deliver the EHP through the implementation of the 6 Year Emergency PreService Training Plan. Organization of Health Services The Ministry of Health and Population has the overall responsibility for health care provision in Malawi. It has a Secretary for Health and Population, assisted by an Under Secretary who is
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responsible for the financial and administrative affairs of the MOH. The MOH has six technical divisions: Clinical and Population Services, Nursing, Preventive Health, Technical Support, Planning, Financing and Administration. Below the central level, the MOH is divided into 27 districts. Each district has a District Health Officer (DHO) who is accountable to the Principal Secretary. The DHO and his/her team run the District Hospital and the peripheral health units which consist of health centres, dispensaries and mobile clinics). A new government policy on national decentralization has been approved in order to devolve administrative authority to the district level and as a result to decentralize health services to District Assemblies as the local governance structures. This will necessitate direct budgetary allocation to the districts thus making District Health Management Teams (DHMTs) in turn to be accountable to the District Assemblies for decisions on financial planning and expenditures. The DHO will have the responsibility for the management of all health services in the district. A 1998 functional review led to the abolition of the three regional health offices, with monitoring and supervision responsibility shifting back to the centre. This proved unsuccessful, with the result that the MOH has decided to establish zonal offices, each providing support to five to six districts, but not having management responsibility. Their function will include technical advice and facilitation support of decentralization, EHP implementation, and inter-district collaboration. Health Service Provision and Infrastructurei The public health service in Malawi is delivered at primary, secondary and tertiary levels through a range of maternity units, dispensaries, health centres, and district and central hospitals, all linked through a referral system. District hospitals and CHAM hospitals, although some have specialist functions, provide secondary level health care services. The secondary level provides mainly back up services to those provided at the primary level including surgical services, mostly obstetric emergencies, and general medical and paediatric in-patient care for common acute conditions. At present, tertiary level hospitals provide services similar to those at the secondary level, along with a small range of specialist surgical interventions. The Ministry of Health and Population provides about 60% and the Christian Health Association of Malawi (CHAM) provides 37% all-formal health care services in Malawi. The Ministry of Local Government provides about 1% of health services. Private practitioners, commercial companies, army and police, provide 2% of health services. Traditional Birth Attendants deliver approximately 25% of the pregnant women and most communities have a traditional healer. Other sources health services are also delivered through a network of community-based workers consisting of Health Surveillance Assistants, community based distributors, other community volunteers and Faith Healing groups. The table below shows the distribution of health facilities by type and ownership. In all, there are 617 health facilities of which 392 (63.5%) are operated by the Ministry of Health and 161 (26.09%) by the Christian Association of Malawi (CHAM). While Ministry of Health services are free, CHAM services are chargeable at small rate. The quality of services provided at CHAM facilities is considered to be better than those at Ministry of Health facilities. The remaining facilities are operated by NGOs such as Banjala Mutsugolo and by the Local Government.
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Health Facilities in Malawi: Ownership and Type Type BLM CHAM LG Central Hospital Clinic 27 8 4 Dispensary 8 4 Hospitals 22 Health Centre 1 115 12 Community Hospital 17 Maternity 1 12 Psychiatric Hospital 1 Rehabilitation 1 VCT Centre BLM: Banja La Mtsogolo is a reproductive health NGO CHAM: Christian Health Association of Malawi LG: Local Government MOH: Ministry of Health NGO: referrals to not for profit NGOs
MOH 4 2 54 22 288 19 2 1 1
NGO 1
Total 4 42 66 44 416 36 15 2 2 146
Source: Health System Strengthening, Global Fund Proposal 2005 The Christian Health Association of Malawi (CHAM) is made up of independent church-related and other private voluntary agency facilities. CHAM is a particularly important provider in rural areas where it operates about 160 health units. Most of these health institutions provide training for nurses and other health personnel.The government works closely with CHAM, assisting CHAM by providing it with an annual grant and receiving large numbers of nurses trained in CHAM schools. About 40% of their operating funds come from government mainly covering staff salaries, 30% from donors and 30% from user fees. The NGO Banja La Mtsogolo (BLM) provides sexual and reproductive healthcare services through private clinics across Malawi. A number of other organizations provide HIV and AIDS related services on a smaller scale including The Lighthouse, MACRO, the USAID-funded Umoyo network, and two MSF-funded and four UNICEF-funded district pilot sites. The private for-profit sector in Malawi is small and fragmented at present. Accessibility to health facilities in Malawi is generally good, with up to 84% of the population within 5 to 8 km of a health facility. Nevertheless, accessibility in some districts is poorer than in others. The current total number of hospital beds is 14,128 (707 persons/hospital bed) of which 60% are in government health facilities while 37% belong to CHAM and 3% belong to local authorities and other providers. Most of the country‟s health infrastructure is old, inadequate for the patient load, dilapidated and in desperate need of repair and ongoing maintenance. Many health centres lack water and electricity. Infrastructural inadequacies reflect the severe shortage of funds for the public health system over many years. A recent assessment of health facilities indicated that a significant number of them need rehabilitation and upgrading in order to be able to provide the full Essential Health Package (EHP). Most of these facilities have serious shortages of essential drugs as well as essential medical diagnostic equipment and surgical supplies. This is hampering Government‟s effort to minimize morbidity from treatable diseases such as malaria, tuberculosis, etc. While many improvements have been made to the pharmaceutical system, additional steps should be taken to strengthen it. In this regard, the World Bank is assisting the MOH in the establishment of a drug revolving fund, to ensure the supply of drugs through a cost-sharing scheme at the tertiary level.
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Human Resources for Health The workforce in the health sector as a whole is estimated at 15,700, according to the Human Resource Plan, 1999-2004.This does not include an estimated 3,600 traditional birth attendants and 2,300 community-based distributor agents for contraceptives. 68% of the workforce are employees of the Ministry of Health. The CHAM employs some 26% with the remaining 6% divided among local government, police, army and non-governmental organizations (NGOs). The current level of staffing in Malawi‟s public health service is inadequate to maintain a minimum level of health care, and is very low by African standards. In reality, 90 percent of public health facilities lack the capacity to offer even the most basic health care. ii The lack of capacity to deliver health services is most severe in rural areas where primary health care is severely compromised. The distribution pattern of staff favours urban areas at the expense of rural areas, where 87% of the population reside. This is due to the unattractive working environment in the rural areas, such as the lack of social amenities and accommodation. The scaling up of the health strategy to build service delivery under the Essential Health Package, has been critically slowed, with only 10% of 617 facilities satisfying the human resource requirements for delivering the Essential Health Package (four professional or technical employees). iii Current and Required Human Resources in Malawi Health Care Cadre Target Current Current % of actual Cadre Number Vacancies staff to target for in Posts Malawi Physicians 433 139 294 32 Nurses 8440 4717 3723 56 Clinical Officers 1405 942 463 67 Medical Assistants 1500 718 782 48 Laboratory Technicians 507 251 256 50 Pharmacist Technicians 285 93 192 33 Environmental Health Officers 1662 304 1358 18 Health Surveillance Assistants 12615 3600 7400 29 Numbers are based on Ministry of Health and Christian Health Association of Malawi figures. Source: Health Systems Strengthening, Global Fund Proposal 2005 According to the Ministry of Health, the total number of physicians in the country is 219, being one doctor per 45,662 Malawians, well below the WHO average ratio of 1 to 10,000. For Malawi to reach this ratio, 800 additional doctors are required. The MOH has 108 general practitioners and specialists, while CHAM, the College of Medicine and the private sector have 34, 21 and 56 medical officers respectively. Skilled positions such as surgeons have vacancy rates as high as 85%. There are currently no pathologists in the public sector in the country and only 17 surgeons and 11 obstetricians. Ten districts are without a public sector doctor and four without a doctor at all. The College of Medicine produces about 20 doctors per year. Considering its population, this figure is extremely low and this has resulted in heavy reliance on other categories of health professionals such as clinical officers and nurses to carryout some of the work for doctors. There is a critical nursing shortage in Malawi with a population ratio 1 to 3500, compared with 1 to 1000 for Africa as a whole; nursing to patient ratios range from 1:50 – 1:120 with the majority of staff being lowly skilled workers. Up to 65% of the public sector nursing posts are unfilled and six districts have a nursing vacancy rate of over 70%. Over half of 29 districts have less than 1.5 nurses per facility, and five districts have less than one. Over 95% of registered nurses are urban
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based leaving significantly higher vacancy rates in under-served rural areas. Community nurses at village level in rural areas are especially in short supply diminishing access to professional home-based care, school health and other supervisory services. In the 970-bed Lilongwe based Kamuzu Central Hospital, only 169 nurses were practicing in mid-2004, compared to the 520 nurses whom the hospital was authorized to employ. There is currently a shortfall in the hospital of 400 nurses leaving wards that require 10-12 nurses staffed with 0-1 nurses, and nurses whom are regularly required to carry out 16-hour shifts. There are also 53% vacancies among clinical officers.iv Community and home-based care has suffered with the significant shortfall of Health Surveillance Assistants (HSAs) leaving many rural areas underserved. The EHP Malawi target is to have 1 HSA per 1,000 populations. This would require over 12,615 HSAs, yet there are only 3838 currently employed in the health sector. This creates a significant barrier to service access especially in the neediest areas. HSAs are the core service providers at community level and provide a major contribution to increasing access to the HIV/AIDS continuum of care and TB and malaria EHP services. They are the entry point for village level services and most homes and families of those affected by acute illness and HIV/AIDS/TB and malaria depend on HSAs for services. Human Resource Crisis in the Health Sector There are several reasons for the human resource crisis in the health sector: poor retention of existing staff due to low pay, poor working conditions high workloads, weak supervision, inadequate housing, shortages supplies, weak and unresponsive HR management and a resulting decline in morale; and inadequate supply of trained workers. Human resources for health was not a major theme in the health reform movements of the 1980s and 1990s under structural adjustment programmes. As a result there has been underinvestment in training. Some of the investment made in training is lost as staff chose to move out of the public health service into better-paid and/or less frustrating work internationally and increasingly to domestic posts with growth in research jobs and at NGOs especially HIV/AIDS jobs. There s also movement of health workers from government run facilities to CHAM facilities, because despite government paying the salaries of these heath workers regardless of whether they work at a CHAM facility or a government run facility , in CHAM facilities these workers receive additional benefits. v The most significant factors contributing to poor staff retention include: Poor remuneration and benefits, the single most important reason why staff leave the public health service. The 2001/02 level of real average compensation was less than half of its 1980 level. Poor working environments such as overcrowded facilities with low nurse: patient ratios, heavy workloads, unreliable supplies and equipment, lack of HIV/AIDS protective supplies (i.e. gloves), and no water at many district hospitals or electricity in health centres; Little or no career advancement opportunity with low training institution capacity to increase enrolment; Poor living conditions including poor or no housing available. The lack of labour supply in trained public health staff can be attributed to: The lack of resources, including the lack of physical infrastructure, available to the training institutions to increase student enrolment as well as to provide teaching curricula for ART/HIV/AIDS/TB/malaria case management. A severe shortage of adequately trained tutors According to a national assessment, there is a current shortfall of almost 1500 students enrolled in training institutions. There are also no guarantees that newly trained health service workers
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will remain in the public sector, only 70 of approximately 500 graduating nurses from government funded training entered the public health service in 2003. Staffing is also inadequate to roll out antiretroviral therapy and other services related to HIV/AIDS. The Ministry of Health estimated that in order to achieve the government target of providing antiretroviral therapy to 80 000 people by December 2005, according to international staffing norms, require 170 full-time clinical officers, 170 full-time nurses and 170 counsellors. A workload analysis of ART clinics carried out in Malawi showed that for every 1000 PLWHA on ART roughly 1 part-time doctor, 2 full-time clinical officers, 2 nurses, 2 counsellors and 1 support staff is needed. In addition, staff are required for HIV testing and PMTCT services at health facility level, all of whom must receive special training would have been required. vi In addition, staff would have been required for complementary activities including voluntary counselling and testing, treating opportunistic infections and preventing mother-to-child transmission. Illnesses related to HIV/AIDS account for an estimated 60% of hospital occupancy, and existing human resources are not capable of supporting this. This will place considerable further burden on human resource capacity in the health sector. The acute shortages of health facility personnel need to be addressed immediately but longerterm solutions are also important. It is essential to increase the training capacity of health workers in order to have adequate numbers of qualified staff for the future. The Ministry of Health recognises that addressing the staffing crisis in the health sector will improve services to those affected by HIV, TB and malaria through improved utilisation of quality health services, which better meet patient needs. The Ministry of Health has embarked on a Emergency Human Resources Program to tackle the human resources crisis in the health sector. According to the draft human resource strategic plan for 2003 – 2013, the current major concern of the MOH is to address the critical shortage of human resources resulting from inadequate capacity of training institutions to produce the numbers of human resources required to deliver the EHP. This strategy revolves around the sound implementation of the 6-year Emergency PreService Training Plan for the sector which gives priority to financing adequate numbers of trained and skilled personnel for all health facilities (including CHAM); filling vacant posts; strengthening human resources retention; and providing in-service training. The civil service has a general policy on training that applies to all civil servants including MOH personnel. In the health sector two types of training are provided basic and post-basic (which incorporates external and inservice training). Basic training is delivered through an array of institutions primarily within the Ministry of Education, MOH and CHAM. In addition, the government has also embarked on an initiative to re-engage health workers that have left the public service, as detailed in the article below. Government to Re-Engage Retired Nurses Government has unveiled plans to re-engage retired nurses and midwives to beef up staff levels in public hospitals to achieve a desirable nurse to patient ratio. Health Services Commission Executive Secretary Simon Sapa said in an interview on Wednesday the Ministry of Health and Population was on a drive to maintain a good nurse to patient ratio and that re-engagement of retired staff was one of the main options. “In the next few weeks we will be flying adverts calling on retired nurses and midwives that are fit to consider coming back,” he said. Currently, Sapa said, the commission is carrying out a study to trace the retired staff to seek their views on how government can retain its human resource. He said government intends to improve working conditions of staff in the health ministry to fight brain drain that has over the recent years hit the ministry mainly due to uncompetitive salaries. Last year, then Deputy Minister of Health Frank
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Mwenifumbo reported that the ministry was short of 2,178 nurses. This situation, he said, left some 26 district hospitals across the country with an average of less than 1.5 nurses per health facility. Health officials are on record to have said that one nurse in Malawi serves 5,000 patients which, they said, is 1,000 more than the World Health Organisation recommended ratio. Through the tracer study, Sapa said, government wants to know why it continues losing human resource to the private sector within and outside the country.
Malawi Nation, 2006-01-20
The Emergency Human Resource Programmevii In 2004 the government of Malawi declared the human resources in the health sector as a crisis and reported that the health sector had collapsed. Despite the request for funding to build human resource capacity, this had been refused by the Global Fund in the Round 1 grant and funding was substantially reduced. Then in 2004, and the Executive Director of UNAIDS Peter Piot and Permanent Secreatry of DFID Sir Suma Chakrabarti visited Malawi and jointly stated that the health sector human capacity crisis in Malawi is an emergency „requiring exceptional measures that might otherwise be dismissed as unsustainable‟. This lead to a 6-year Human Resources Emergency Relief Plan (US$ 273 million), 100 million from DFID 100 million from GFATM (Round I and V) and the rest from the SWAp. The Plan has five objectives: To provide stop-gap external support for critical posts (mostly teaching) providing 50 volunteer doctors, nurse tutors per year while Malawians staff trained To expand training capacity by 50% on average To improve retention and re-engagement with 52% taxed top-ups for 11 key cadres of GoM and CHAM staff, recruitment and re-engagement programme, bonding initiative, rural location incentives, staff housing To provide HR management support for the Ministry of Health for at least 2 years. To monitor and evaluate HR initiatives and link this to the SWAp M&E framework. Health Care Financing Health care financing in Malawi is composed of: Government financing through voted expenditure and subventions to other providers Donor support through Government‟s development budget, commodity aid and direct support to programs and support to other providers Private sector expenditure on health care, and out of pocket expenditure of household members. According to the National Health Accounts for 1998/99 (the only year for which such an analysis has been undertaken), total health expenditure was roughly USD12.4 per capita, of which government accounted for 25%, and donors for around 30%. Putting Malawi Government and donor sources together, public funds accounted for 55% of health expenditure, the total of which was estimated at USD 123.9m or 7% of GDP. Private sources accounted for the remaining 45%, of which more than half came from out-of-pocket expenditures by households. The Government has been the main source of recurrent health care expenditure in Malawi. Although the budgetary allocation to the Ministry of Health approved by Parliament has been rising, this has not met the increasing needs of the health sector. In the past decade, economic difficulties (devaluation and inflation) have led to a decline in the real value of health
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expenditure, both from the recurrent budget and the GOM contribution to the development budget. Thus, the expansion of the health infrastructure could no longer be maintained with adequate recurrent spending and the budget is no longer sufficient for covering the needs of an ever-increasing population. The Ministry of Health budget for FY 2002/03 was MK4.5bn, or 12.3% of total voted recurrent and capital funding. This compares with a figure of MK5.3 billion (15.1%) in FY 2001/02, and therefore represents both a decrease of 14% in nominal terms, and a reduced share of the overall (voted) recurrent and capital budget. This is largely due to a fall in the development budget, and in particular, the externally funded component, which was a result of some donors that temporarily withdraw their support because of corruption and misappropriation of public funds. Ministry of Health Budget 2001 to 2003 (Billion MK) 2001-02 Approved 2002-03 Approved MOH National % MOH National Recurrent 3.4 21.4 15.9 3.6 24.3 Capital 1.9 13.7 13.8 0.9 12.5 Total 5.3 35.1 15.1 4.5 36.9 Source: Ministry of Health, 2002 in African Development Fund 2006
% 14.9 7.5 12.3
In response to the inability of the government to meet the financial needs of health sector, the government had to rethink its health strategy resulting in health policy detailed earlier adopting a Programme of Work for 2004 to 2010 to be implemented on the basis of a SWAp for financing the EHP. Funding of the programmes under the POW will cost USD 735 million and will be jointly financed by the Government and its Development Partners as indicated in the table below. Cost of the POW Annual Programme Cost (million USD)
04/05 05/06 06/07 07/08 08/09 09/10 Total % of total
Programme I Programme II Programme III Programme IV Programme V Programme VI Total
28.2 15.3 6.2 7.0 24.0 9.4 90.0
34.1 29.7 7.6 6.7 27.3 10.4 116.0
39.1 19.9 8.1 9.0 30.1 10.9 117.0
44.6 22.2 8.6 10.0 30.0 12.0 117.0
48.6 24.9 8.9 10.0 32.0 12.6 127.0
53.1 27.9 9.4 11.0 33.0 13.2 137.0
247.7 139.9 48.8 53.7 176.4 68.6 148.0
34.0 19.0 6.6 7.4 23.7 9.3 100.0
Source: African Development Fund 2006 Over a period of 6 years, allocations for the POW work out to about an average of USD 10.3 per capita per year. This is higher than the 55% contribution made by government and donors to per capita health expenditure in 1998/99 (USD 6.82 of USD 12.4). However, the Government made a policy decision that all services within the Essential Health Package will be delivered free-ofcharge, this seems unachievable under current allocations of the POW as it would mean lower per capita expenditure on health than that of 1999/98. User fees are currently charged in CHAM facilities, local government facilities, private facilities, and in paying outpatient departments and wards in government hospitals (both district and central). Debate continues as to how to handle the current policy of CHAM to charge for health services within the EHP.
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The majority of finance for the POW will need to come from donors, and the proportion of donor finance in the POW is expected to rise over time. Current sources of financing for the programme are indicated in the table below. Source of Financing for the POW Source ADF World Bank DFID* NORAD OPEC Fund UNFPA Government Other development partners** Total
Total (USD millions) Percentage %
21.85 15.00 182.00 60.00 8.00 0.10 210.00 238.05 735.00
3 2 25 8 1 0.01 29 31 100
* this includes GBP 55 million earmarked for the Emergency Human Resource Programme ** This includes unpooled funds budgeted for in the POW Source: African Development Fund 2006 The six-year POW will be implemented adopting various funding modalities that will be mutually agreed upon. The modalities intend to capture as many funding sources as possible and shall neither exclude nor restrict contributions to the implementation of the POW by Development Partners that have different funding mechanisms. It is anticipated that all support will come under one or more of the funding modalities. Provisions have been made for the following modes of funding in order to accommodate specific financing requirements of different donors viii: Mode I (Pool/Basket Funding) contributions from Collaborating Partners will also be channelled directly to the MOH and deposited in a common bank account. These funds will be controlled by the MOH and they will be available for the entire sector. (This is the preferred mode by the MOH). Mode II contributions from Collaborating Partners will be channelled directly to the MOH. These funds will be controlled by the MOH and they will be available for the entire sector. Unlike Mode I, funds will be deposited in separate individual accounts, not in a common account. Mode III contributions from Collaborating Partners will be channelled directly to the MOH. These funds will be controlled by the MOH. Whilst these funds will be deposited in separate individual bank accounts as in Mode II, they are only for specific activity/ies. Mode IV these funds will be channelled directly to either an activity implementation team or a relevant entity and are not controlled by the MOH. They will be available only for a specific activity under the Sub-Programme of POW. They will be deposited in separate individual accounts as appropriate. Agreement has been made between the MOH and a core group of partners pooling all or at least a part of their resources in the basket fund (DFID, NORAD, World Bank and UNFPA) to use common implementation arrangements for planning and budgeting including procurement, financial management and technical assistance. Other Development Partners are expected to join the core group in the near future. The Bank Group will contribute its resources under Mode III until after the amendment of the article of the Fund Agreement which restricts usage of ADF resources to goods and services originating from the member countries of the ADB. As indicated above, the USD 735 includes unpooled funds, which Government is looking forward to being
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reprogrammed to basket funding. In the meantime, it is possible for a donor in the pool to also fund outside the pool and for other donors outside the pool to fund the programme using separate projects and earmarked funds (that is currently the case for WHO, UNICEF, USAID, JICA, GTZ). Health Financing 2004/2005ix In 2004/05, total approved budget to the Ministry of Health was K9.138 billion, of which K4.849 was total recurrent budget and K4.289 billion was development budget. The recurrent budget was broken down into personal emoluments (K1.99 billion) and ORT for K2.86. Revised figures show that total expenditure for the Ministry went beyond the approved amount by 4 % to K9.5 billion.
The development budget exceeds K4.289 billion when donor funds are considered. Below is a table listing current programmes and projects that fall under the development budget and funding sources.
The table below shows the outputs and achievements of the programmes and projects under the
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development budget.
According to information gathered from the Ministry of Health Headquarters, the total resource package for the year 2004/ 05 was K17.857 billion (including K3.438 billion from the Global Fund for the National AIDS Commission (NAC). The table below gives the sources of funding per donor.
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The Impact of HIV/AIDS on Malawi Ministry of Health and Population (MoHP)x Methodological considerations In seeking to establish the impacts of HIV/AIDS on the MoHP and on health workers, this study found that information systems are in disarray. This meant that not all information required was found. The findings presented here are therefore only exploratory. More detailed studies, focusing on a selected sample of health workers, are needed to have a more thorough analysis of the impact of HIV/AIDS on the MoHP. Attrition General attrition levels Death is the highest cause of attrition in the MoHP, followed by retirement, resignation, dismissal and redundancy (see Table 26). In fact, death-related attrition is more than the other causes combined. Death increases steadily throughout the 1990s and peaks in 1999, after which it drops.
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Retirement reaches a high point in 1993, when the Government strictly enforced its retirement policy. Between 1994 and 1999, it remains fairly constant, until it increases again in 2000. Resignation stays relatively constant until 1996, after which it increases substantially. This was around the same time when the health service was liberalised. As a result, many health workers moved to private practices with better benefits. Graph 14 captures these trends in graphic form.
Attrition by sex and age group Death-related attrition by sex and age group is reflected in Table 27. Death is particularly high in the age groups 30-34 (19%), 35-39 (21%) and 40-44 (19%). It is lowest in the 20-24 years age group (1%), followed by the age group 25-29 years (8%). The high percentage of death noted in young adults between 30-44 years old reflects broader trends in Malawi, as noted by the NAC. Most of these young adults are sexually active – and have been for some time, bearing in mind the period of delay between HIV infection and AIDS-related death. This situation has the potential of depriving the ministry of quality leadership, because this is generally the age group that is likely to take up senior management positions. It will also distort output levels, quality of work and career structures.
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Table 27 also shows that in absolute numbers more men (56%) die than women (44%). Graph 15 further captures these trends by sex and age group. It shows that both male and female deaths peak in the 35-39 age group. This is at variance with the assessment of the NAC, which states that female deaths peak at a younger age group in the general population. However, the graph shows that female deaths start to peak slightly earlier than male deaths. Women form the bulk of health workers and mostly work at the frontline. They are therefore crucial in the implementation of the Primary Health Care strategy.
Attrition by occupational category Table 28 shows death rates by occupational categories for selected years. Average death rates for the period show that the highest death rate is experienced by Laboratory Technicians (47.5), followed by Clinical Officers (31.8), Environmental Health Workers (29.8), Medical Assistants (23.3), Enrolled Nurses (20.3) and Registered Nurses (15). The lowest average death rate occurs among Health Surveillance Assistants (6). Thus, most occupational categories show a higher mortality rate than the average adult mortality rate of 11.2 in Malawi (DHS, 2000).
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To rectify the shortfalls inherent in the crude mortality rates, standardised mortality ratios (SMRs) have been calculated for selected occupational categories using the average adult mortality rate. They cover the period 1996-1999. The findings are reflected in Table 29. Where the SMR exceeds 100 it means that mortality is higher than average mortality in the general population of Malawi.
The table shows higher than average SMR values for laboratory technicians, clinical officers, medical assistants, registered nurses and enrolled nurses. In fact, the SMR for laboratory technicians is 10 times more than the average mortality in the general population. The SMR of clinical officers is almost three times over the average mortality of 100, while that of registered nurses and medical assistants is more than double this benchmark. The SMR of enrolled nurses also exceeds 100. This indicates excess mortality for these officers, who are central to the delivery of health care at all levels of care. HIV/AIDS-related mortality The main causes of death as listed in the personnel files of the dead included short illness and long illness. In a few cases, specific diseases such as TB, chronic productive cough and pneumonia were indicated. Although long illness and TB or pneumonia can be indicators of HIV/AIDS, in the absence of clinical diagnosis it is difficult to determine the number of people who have died of HIV/AIDS.
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As Table 30 shows, 9.8% of deaths in the MoHP between 1995 and 2000 are likely to be caused by HIV/AIDS. When applied to the total number of deaths (1,462) in the MoHP between 19902000, it means that 143 deaths could be HIV/AIDS-related. This figure is an underestimate, because the excess mortality experienced in the Ministry suggests a significantly higher number of HIV/AIDS deaths than the estimated number. Based on the information contained in the DHS (2000) report and other research reports, the only explanation for the excess deaths in the Ministry is HIV/AIDS. This argument is validated by the data in Table 27, which indicates that 68% of deaths occurred in the age group of 20-44. Morbidity and absenteeism Just like in most Public Service institutions, absenteeism and its causes are not currently recorded in the MoHP. According to the Human Resource Department in the ministry, late reporting for work in the morning and after lunch as well as early departure were other manifestations of absenteeism. Common causes for absenteeism included employee own sickness; attending funerals; time spent in banks; declining real incomes; and, worsening conditions of employment. Although there is no system for absence management in the MoHP, some MoHP referral, district and peripheral institutions do record absenteeism and related causes. One example is the Nursing Department at Zomba Central Hospital. Other departments at the hospital do not record absenteeism. This shows that recording of absenteeism is largely based on the personal initiative of supervisors. Some have argued that even if they were to create absence management systems in their departments, there are no clear consequences for those who absent themselves. The highest recorded cause of absenteeism in Zomba Central Hospital is sickness, followed by funeral attendance and attending to sick people. Graph 16 shows the number of days lost due to sickness between 1995 and 2000 for nurses at Zomba Central Hospital. On average, every year 498 days are lost to 100 nurses concerned, bringing the average to five days per nurse per annum. The graph shows that morbidity increases substantially from 1995 to 1996. After a slight drop in 1997, it increases again before falling significantly in the year 2000. Major diseases causing nurse morbidity at Zomba Central Hospital are indicated as tuberculosis, kaposis sarcoma, pneumonia and malaria. Almost all departments at MoHP headquarters have chronically ill officers, whereas at Zomba Central Hospital there are more chronically ill officers and staff on sick leave. The evidence from Zomba hospital suggests that absenteeism due to morbidity in the Ministry is high. Consequently, a lot of productive time is lost.
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Vacancy analysis For many years, the Health sector has had a shortage of trained health personnel. Table 31 gives a breakdown of authorised establishments by selected staff category.
With the exception of Medical Officer, Registered Nurse and Health Assistant, establishments for all staff categories have increased between 1992 and 2000. There has been a very large expansion of authorised establishment of Laboratory Assistants and Pharmacy Assistants. As we shall see later, these two categories have large vacancies (see Table 32). This may indicate inadequate numbers coming out of training and lack of mechanisms to attract and maintain them in the MoHP as well as an unrealistic establishment expansion. Also, the impact of deaths cannot be ruled out, considering the excess deaths experienced by most cadres (see Table 29). An analysis of vacancy levels in the MoHP shows that there has been a general improvement in the staffing situation of the MoHP relative to the authorised establishment in the clinical, nursing and preventive sections.
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However, the positive picture portrayed in 2000 may not mean improvements in actual numbers in post. Rather, it may be a result of the large establishment resulting from the change management functional review report. Staff shortfalls present both opportunities and challenges for the government as a whole and for the MoHP in particular when planning the reforms. Large vacancies result in ineffectiveness and inefficiency in the delivery of services and have the potential to negatively affect the pace and quality of reforms both at macro and micro levels.
To meet the strategy requirements, the National Health Human Resource Plan (1999-2004) is giving priority to filling the posts of Laboratory Assistant and Technician, Medical Officer, Radiography Assistant and Technician, Enrolled Nurse and Medical Assistant. However, recruitment in the MoHP is constrained by the bureaucratic recruitment procedure and limited financial resources. Discussions with Ministry officials revealed that it takes up to 12 months to fill a post. Table 32 does not indicate the vacancy levels between rural and urban facilities. It also does not show the vacancies relative to the different health care levels (primary, secondary and tertiary). However, the National Health Human Resource Plan (1999-2004) in the MoHP indicates large vacancies in rural areas at primary care level. This is certainly jeopardising the Ministry‟s efforts to implement a comprehensive Primary Health Care (PHC) strategy. As Table 32 shows, the situation in the technical support area is particularly depressing. There is a high vacancy rate. It is important to note that health care provision is effectively delivered by a team. Thus, understaffing prevalent in the technical support area may not only create service problems in this area, but also adversely affect the activities of other staff categories.
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Workload analysis Among other things, staff to staff ratios measure an officer span of control and hence effectiveness of the supervision system. High ratios have the potential to negatively disrupt the supervision system by making it impossible for supervisors to coordinate various responsibilities and activities. This results in fragmented and vertical implementation of health programmes, which may ultimately compromise the quality of service provision. As Table 33 shows, the ratio of Doctor to Nurse is disproportionate to allow for effective supervision, especially since Doctors are in charge of large health care facilities and programmes with a myriad of responsibilities. The Clinical Officer to Nurse ratio is relatively big. Similarly, large ratios for Health Assistant to Health Surveillance Assistant will hamper effective health care coverage.
Another way of assessing the workload of health workers is to look at the staff : population ratio. Although this measure has shortcomings, it can be an important indicator of the workload of personnel. There are no standard staff : population ratios in the MoHP. As Table 34 shows, the ratio of most staff categories to the total population of Malawi has decreased over time, with the exception of Registered Nurses, Public Health Nurses (data not available for 2000), Health Assistants and Medical Assistants. The ratio of Pharmacy Assistants to the general population has decreased until 1998, after which it shows an increase. However, it is important to bear in mind that during the period under review epidemiological patterns may have changed and become more complex. Occupational risk of infection with blood-borne and other infectious diseases may also have increased within the health sector. This has added to the psychosocial stress of managing terminal illness under conditions of understaffing and inadequate resource allocation. These factors have the potential of increasing actual workloads for health personnel.
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To sum up, HIV/AIDS-related morbidity and mortality amongst health workers are likely to have a disastrous impact on the Ministry. It results in a decline in productivity. Furthermore, deaths lead to a loss of overall experience among its labour force thereby reducing accumulated knowledge. As a consequence, the MoHP will face higher replacement and training costs. It will also experience a significant increase in expenditure on benefits, medical care and funerals. These impacts will be discussed below. Impact on productivity and performance Morbidity reduces the productivity of human capital, while mortality reduces the number of healthy workers, coinciding with a loss of skills and experience. The rise in morbidity and mortality, resulting in higher levels of absenteeism amongst employees and higher vacancy rates in the MoHP, will increase the workload of remaining officers. Consequently, the capacity of the MoHP to deliver health services will be compromised. As Table 34 suggests, high staff : population ratios indicate that the officers in the Ministry have high workloads that affect their productivity and performance, impeding on the coverage and quality of service delivery. This finding was supported by anecdotal evidence from the Ministry. Financial implications Training and recruitment Table 35 shows the annual cost for the training of paramedical workers. During 1990 and 2000, a total of 290 paramedical deaths is recorded. Most paramedical training is for three years. Thus, to replace these health workers would cost a total of MK 13,050,000 (basic training).
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In addition to training costs, the Department of Human Resource Management and Development in the Ministry suggests that substantial costs are incurred in recruiting staff. These include costs for advertisement, postal stamps, stationary and conducting interviews, which includes expenditure on accommodation, per-diem and transport. However, the Department was unable to calculate how much it spends on these costs. Funeral costs The government policy on material support for funerals includes the provision of a coffin and three vehicles for a member of staff. However, due to a lack of resources only two vehicles are provided. Like the other Ministries surveyed, the MoHP does not calculate the costs of HIV/AIDSrelated morbidity and death, nor does it have a budget line item for funerals. However, its Department of Human Resource Management and Development suggested that funeral-related expenditure include direct and indirect costs. Direct costs includes the coffin (which costs on average MK 10,000), wreaths, transport to burial place, and subsistence allowance for the drivers and one official on duty. Indirect costs include transport costs related to funeral arrangements. Box 3 shows that the estimated cost of the funeral of a junior or middle level officer is K45, 720. The costs are at current prices.
A graphic depiction of recent trends in funeral costs for the MoHP is presented in Graph 17. It shows that funeral costs increased annually between 1991 and 1995. The costs fell marginally in 1996, only to increase again until they peak in 1999. Another drop is recorded in 2000, when the costs incurred amounted to MK 9,000,000. In 1990, funeral costs amounted to MK 4,000,000, compared to MK 12,150,000 in 1999 (annual funeral costs have been calculated on current price). The increased funeral costs mean a diversion of resources that could otherwise have been used to provide effective health care to the Malawi population, for example by purchasing drugs or other complimentary resources.
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Because the Ministry offers comprehensive employment benefits, the financial implications of HIV/AIDS-related death will be severe. Graph 18 shows the trend in the amount of deaths benefits given out by the MoHP from 1994 to 2000. During this period, the Ministry paid an increasing amount of death benefits. In 1994, the Ministry paid out MK 1,166,273. This amount rose consistently and reached MK 17,724,549 in 2000. The trend in death benefits portrays a clear picture about the increasing number of staff deaths in the MoHP.
Impact on service provision As highlighted earlier, high levels of absenteeism, vacancy rates and workloads result in a decline in productivity and will compromise the provision of quality health care services. Furthermore, the fact that some of the activities in the Ministry are performed by less qualified staff – a strategy to cope with high levels of vacancies – also undermines the quality of services. For example, ward attendants, especially in health centres, do most of the work that is supposed to be undertaken by nurses. Institutional vulnerability to HIV/AIDS There are various interlocking issues, which make the MoHP vulnerable to the impact of HIV/AIDS. These include the organisational capacity for human resource planning, the increased demand for health services, dwindling resources and a deteriorating working environment. The extent to which the Ministry has workplace interventions on HIV/AIDS is also a significant factor. Human resource planning and HIV/AIDS The Department of Human Resource Management and Development at the MoHP has a Human Resource Planning section, which is, however, inactive. Whereas HIV/AIDS morbidity is not taken into account in the process of human resource planning, death is considered somehow, although not in a very systematic way. Because of the weak Human Resource Planning unit, no rigorous and regular attrition analysis is conducted in the MoHP. Increased demand for health services Discussions with senior managers in the Ministry revealed that demand for health services has increased due to the increased morbidity in the general population caused by HIV/AIDS. Records from the Ministry indicate that HIV/AIDS-related illnesses account for 60% of hospital occupancy. Yet, the output of health services training is not sufficient to meet these increased demands. Furthermore, existing human capacity in the health sector is eroded by HIV/AIDS, which further compromises the ability of the Ministry to meet these demands.
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Dwindling resources Senior managers in the Ministry asserted that although the annual allocation of resources have increased over the years, in real terms resources have proved inadequate in relation to the ever increasing demand for health services. As a result, the services that are provided are both inadequate and poor. Deteriorating working environment The increased demand for health services coupled with the dwindling resources have led to a deteriorating working environment. Most medical personnel no longer find the hospital a conducive work environment. As a result, most health personnel prefer working in the Ministry‟s headquarters rather than in the health facilities, which deliver services to the populace. This deteriorating environment has made recruitment of health personnel, especially nurses, difficult. It has also resulted in numerous resignations of nurses and medical officers. Workplace interventions on HIV/AIDS The MoHP does not have a workplace HIV/AIDS programme. However, service delivery institutions have HIV/AIDS programmes by virtue of being service providers. Service delivery institutions counsel their staff about HIV/AIDS and provide support to individuals in need. They run in-service education on HIV/AIDS and infection prevention practices. Anecdotal evidence from hospital staff indicates the programme has been a success. The key players at hospital level are nurses who include STI providers, HIV/AIDS coordinators and HIV/AIDS counsellors. They need financial support for training sessions. There is also a need to have a specific programme for health workers. Conclusion The findings of the study show that death is the largest cause of attrition in the MoHP. Most of those affected are between 30-39 years old. Yet, many of the human resource structures, systems and procedures for coping with attrition in general and HIV/AIDS deaths in particular are either not in place or appear in urgent need of repair and support. Increased mortality results in a decrease in the stock of skilled and experienced labour and leads to increased training and recruitment costs. Similarly, increased morbidity and absenteeism affect productivity and the performance of health workers. Because of inadequate communication between the centre (MoHP headquarters) and service delivery institutions, it is difficult for the authorities at the Ministry to see the impact of HIV/AIDS on services and take appropriate measures. MoHP headquarters do not have an HIV/AIDS prevention and support programme. Service delivery facilities have HIV/AIDS programmes by virtue of being service providers, but these have many limitations, including inadequate funding and lack of recognition for its activities by the majority of health officers.
Taken from: UNDP; The impact of HIV/AIDS on the Malawi Public Service, February 2002.
i
Information for this section has been taken mostly from Health System Strengthening, Portfolio of Grants in Malawi, The Global Fund to Fight AIDS, Tuberculosis and Malaria, 2005 ii Medecins Sans Frontieres, Malawi: Improving AIDS Care, 2005 iii WHO Malawi Summary Country Profile for HIV/AIDS Treatment Scale Up, June 2005. iv Erik Schouten (2006) The Malawian Government‟s Emergency Human Resources Programme; presented at the Kaiser Foundation, World AIDS Conference, 16 August 2006 v Malawi Economic Justice Network; Budget Analysis of the Health Sector for 2005/06; July 2005.
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Erik Schouten (2006) The Malawian Government‟s Emergency Human Resources Programme; presented at the Kaiser Foundation, World AIDS Conference, 16 August 2006 viii African Development Fund (2006) Appraisal Report Support to the Health Sector Programme Republic of Malawi, September 2006 http://www.afdb.org accessed 6 June 2006. ix Malawi Economic Justice Network; Budget Analysis of the Health Sector for 2005/06; July 2005. x UNDP; The impact of HIV/AIDS on the Malawi Public Service, February 2002.
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