Human ResourcesHuman Resourcesand ART Scale-upand ART Scale-up

in Malawiin Malawi

Matt BoxshallMatt Boxshall, Ralf Weigel, Eustice Mhango,, Ralf Weigel, Eustice Mhango,

Erik Schouten, Andreas Jahn, Sam PhiriErik Schouten, Andreas Jahn, Sam Phiri

Human Resources Human Resources CrisisCrisis

Cadre Botswana South Africa Ghana Tanzania Malawi Physicians 28.7 25.1 9.0 4.1 1.6 Nurses 241.0 140.0 64.0 85.2 28.6

Cadre MoH Target In post 2004

Physician 433 139

Nurse 8,440 4,717

Clinical Officer 1,405 942

Medical Assistant 1,500 718

Laboratory Technician 507 251

Pharmacists 285 93

MMR 1,000 per 100,000 live birthsMMR 1,000 per 100,000 live births But routine, protocol driven programs (eg But routine, protocol driven programs (eg

NTP, EPI, ITN) function effectively . . . NTP, EPI, ITN) function effectively . . .

ARV Scale up PlansARV Scale up Plans 850,000 HIV +ve, 80,000 new infections per 850,000 HIV +ve, 80,000 new infections per

annum, 170,000 in need of HAARTannum, 170,000 in need of HAART GFATM HAART arrived in Malawi June 2004, GFATM HAART arrived in Malawi June 2004,

40,000 people had started HAART by end 200540,000 people had started HAART by end 2005 100 clinics nationwide starting patients 100 clinics nationwide starting patients

treatment as of April 2006treatment as of April 2006 5 year ARV Scale-up Plan, 2010 targets;5 year ARV Scale-up Plan, 2010 targets;

– 245,000 ever started,245,000 ever started,– 208,000 Alive and On Treatment208,000 Alive and On Treatment– 45,000 starting ART per year45,000 starting ART per year

Additional Work?Additional Work?

Will ART Scale-up mean additional work for the Will ART Scale-up mean additional work for the Health Sector? If it does, where will the burden of Health Sector? If it does, where will the burden of additional work fall?additional work fall?

Patients with AIDS will require clinical care with or Patients with AIDS will require clinical care with or without ART. without ART.

As numbers on treatment increase, proportion of As numbers on treatment increase, proportion of new cases decreasesnew cases decreases

Focus on routine ARV reviews!Focus on routine ARV reviews! In Malawi, these reviews are carried out by NursesIn Malawi, these reviews are carried out by Nurses

ART Clinic Nursing Station ART Clinic Nursing Station WorkloadWorkload

All patients are first seen by a nurse at each visitAll patients are first seen by a nurse at each visit Review includes screening for OIs & reactions, Review includes screening for OIs & reactions,

discussing adherence, capturing data, dispensing drugsdiscussing adherence, capturing data, dispensing drugs Three rooms see 180 visits per day, 60 per room, just Three rooms see 180 visits per day, 60 per room, just

over 5 minutes per review. over 5 minutes per review. Half our patients come monthly, half every two months. Half our patients come monthly, half every two months.

Approximately 1/3 patients are currently referred on to Approximately 1/3 patients are currently referred on to cliniciansclinicians

We employ 5 or 6 nurses to ensure the rooms are fully We employ 5 or 6 nurses to ensure the rooms are fully operational ; we should plan for 2 nurses for every operational ; we should plan for 2 nurses for every thousand people on treatment. thousand people on treatment.

200,000 patients on ART will require very approximately 200,000 patients on ART will require very approximately 400 nurses, FTE400 nurses, FTE

OptionsOptions

Reducing targets is NOT an optionReducing targets is NOT an option

1.1. Continue as we are – nurse led Continue as we are – nurse led reviewsreviews

2.2. Reduce the time per nurse reviewReduce the time per nurse review

3.3. Reduce the frequency of reviewReduce the frequency of review

4.4. Shift burden of reviews to other Shift burden of reviews to other cadrescadres

HSA ARV Officers?HSA ARV Officers? TB program is the paradigm TB program is the paradigm Specialist vs GeneralistSpecialist vs Generalist Program integrationProgram integration Professional boundaries – nurse Professional boundaries – nurse

rolesroles Decision making – limits of protocolDecision making – limits of protocol SupervisionSupervision

ConclusionsConclusions&&

ThanksThanks