Lessons learned in HIV Funding and HRH Strengthening

Vienna, 17 July 2010

Dr Frank ChimbwandiraHIV and AIDS DepartmentMinistry of HealthMalawi

Malawi: Some IndicatorsPopulation 13 millionGDP (US$) 265HDI 0.493 (160)Adult HIV prevalence (15-49 year olds) 12% (U=16% , R=11%)PLHIV 984,000People in need for ART (CD4≤350 cells/mm³) 433,000Population per nurse 1,800Population per physician 49,000PLHIV per nurse 135PLHIV per physician 3,700Total Health Expenditure (average exchange rate) US$ 21

Malawi’s health system is heavily constrained, yet …

… the coverage of the programme is higher than what one would expect on the basis of existing capacity

• By the end of March 2010 over 211,000 people were alive and on (coverage 49% based on CD4 cut-off of 350 cells/mm³)

• In 2009 over 1.7 million people tested and counselled for HIV

• ART services provided in 370 health facilities, PMTCT in 650 health facilities and HTC in more than 850 health facilities in the country.

Main question How to develop a successful HIV programme without undermining

other health services? Or, even better. Could the HIV programme support the development of other health services?

Design of the programme

- Base the programme on realities in the health sector

Address HRH issues

- Make optimal use of existing staff (task shifting)- Make health workers a special target in the HIV programme- Advocate for improving HRH improvements

Based on realities – a public health approach

Reduce complexity of the interventions to the bare minimum!!!

Maximise health gain with (very) limited resources – standardisation; same approach in Government, mission and

private sector (NGOs and PFP)– simplification; focus on one regimen for all, make the ART and

PMTCT programme independent from laboratory monitoring, simple drug distribution system based on kit system, increase period between visits

– short training (5 days for ART programme)– supervision and monitoring (strong focus and standardised

M&E and supervision)– shifting and sharing of tasks (Cos, MAs and nurses can initiate

ART)

Task Shifting• 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 - HSAs)

• Role of HSAs to be further developed and role of Expert patients to be defined.

Make health workers a special target group

•Health workers were special targets in the scale up plan–Care of Carer Programme

•Health workers are part of the population in need

-The ART programme needs approximately 800 fte HWs

- The ART programme started over 3,000 HWs on ART

Address HRH issuesAbsolute 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

Advocate for support for HSSIn 2004 the HIV programme strongly rallied to support HRH and ensured the funding for a 6-year Emergency Human Resource Relief Programme (EHRRP) as the number of health workers was the most limiting factor to scale up the programme. The programme (US$ 270 million) was funded by GFATM and DFID. And the main objectives were:

– Train more health workers (doubled intake of most cadres)

– Top-up of salaries (52%)– Temporary additional staff (VSO, UNV)

Achievements of the EHRPRelative change in MOH and CHAM staffing for

5 main cadres in Malawi from 2003 to 2009 (2003=100)

-

50

100

150

200

250

2003 2004 2005 2006 2007 2008 2009

Clinical Officer

Nurse

Medical Assistant

Laboratory Technician

Physician

Lessons

• Government –Donor Collaboration was very critical in the development of EHRP

• Commitment • Multi-sectoral involvement was critical

Conclusion

• HIV funding has contributed to HSS through– Recruitment– Retention– Training

• Tuition• Infrastructure

Thank you very much!