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Presentation OutlinePresentation Outline
Malawi’s Response
Challenges and Trends
Lessons Emerging
Impact and Sustainability
Challenges and Challenges and TrendsTrends
In 2000: 20% of Malawian nurses; 60% of Malawian doctors worked abroad.
2004 vacancy rates for critical cadres:
- Surgeons: 98%
- Pathologists: 100%
- Medical specialists: 95%
- Obstetricians: 92%Lack of domestic/international support for
MOH HRH Plan finalized in 2000
Why did this happen?Why did this happen?Insufficient production of health workersLow and declining pay (e.g., 2001/02
average HW wage in real terms was less than half that in 1980)
Poor non-financial terms and conditionsPoor recruitment practices in public
sectorCrumbling health system – poor support
to staffDevastating impact of HIV/AIDS
Malawi’s ResponseMalawi’s Response New government in 2004: fiscal
disciplineIncreased commitment to health
sectorIn turn:
◦donor confidence enhanced ◦ increased preparedness to fund
recurrent expenditure◦momentum for health sector wide
“systems approach”
Malawi’s Response:Malawi’s Response:Policy InterventionsPolicy Interventions
2004: six-year, $272m Emergency Human Resources Program (EHRP) was developed
EHRP nested within the SWAp mechanism
Task shifting: incl. use of community health workers
Reintroduction of Medical Assistants cadre
Revitalization of the CBD ProgramIntroduction of LTPM in pre
service curricula
Emergency Human Resource Emergency Human Resource ProgramProgram1. Expand training capacity by 50% on
average2. Improve retention and re-engagement,
52% taxed top-ups for 11 key cadres of GoM and CHAM staff, recruitment and re-engagement program, bonding initiative, rural location incentives, staff housing
3. Stop-gap external support for critical posts (mostly teaching) - 50 volunteer doctors, nurse tutors per year while Malawians staff trained
4. MOH HR management support: 3 TA for 2yrs
5. M&E – linked to SWAp M&E framework
Task shiftingTask shifting
CBDAs providing contraceptives in the community
Nurses/ MA providing LTPM at HC level
HSAs providing immunizations and health promotion activities including; injectable contraceptives and village clinics at the community
NB- No client satisfaction surveys done on all task shifting.
Incentives for Community Incentives for Community WorkersWorkersHSAs on government payrollProtective wear; umbrella, raincoatsBicyclesCommunity supportRecognition and acknowledgement by
influential leadersPromotion to CBDA supervisorPerformance based awards (Project
Specific)Money for an IGA activity appropriate
to the community.
ImpactImpact
Improved health worker ratios: physicians from 1.1 (2004) to 1.9 (2007); nurses and midwives from 25.5 to 34
Reduced nurse emigration: from 147 (2004) to 23 (2006), to 8 (2007)
Training targets approx being met – falling short of nurse/midwife targets, exceeding doctor/clinical officer/med asst targets
System Impact: Quality System Impact: Quality AssuranceAssurance
Pre and in-service trainingRefresher trainings and annual
reviewsField supervisors conduct weekly visitsMonthly/ Quarterly Supervision by
program staffData managementLinkages and referralsConcerns on loading too much on
HSAs
Impact: Supervision of Impact: Supervision of Community Health workersCommunity Health workersLevelsPrimary level: by Senior CBDA/HSA-
1:15Secondary level: Service
Provider/Program CoordinatorNational level: RHU; FBO;NGO; Private
Sector
Frequency: Monthly by Primary Supervisor; Quarterly by secondary supervisor; National supervisor once per year.
SustainabilitySustainabilityEHRP- modest but promising results Use of salaried field staff such as HSAsVolunteer turnover – depends on incentives All activities steered by central Ministry or
Districts for continuity Streamlined reporting requirements-one
LMISStandardized guidelines & training
materialsCommunity ownership of volunteersStrong supervisory system at community
level
Emerging LessonsEmerging LessonsPolitical and donor commitment: willingness
to support wage bill for EHRP; allow different pay scales sector; concerns about sustainability
Taking a systems approach: only makes sense within overall context of improving health service facilities and management systems.
Phased approach: combination of short and long term and stop gap measures
Deployment: address delays in getting recruits on payroll
CBD Services: concerns about sustainability Pre-service Vs In-service: balancing needs
careful managingNo clear defined role of VHW
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