Scaling up training of nurses in Malawi through partnership with GovernmentBy Potiphar Kumzinda

Background

Christian Health Association of Malawi (CHAM) is an organization that coordinates the health care delivery service for all the member Christian church owned health facilities in Malawi

171 facilities from different churches are registered with CHAM (20 major hospitals, 30 community hospitals, the rest health centers with or without maternity) of which 10 are teaching hospitals.

The facilities provide about 37-40% of the health care service delivery in Malawi 80% of such in rural areas where 80% of poor Malawians live and mostly hard to keep staff working there.

CHAM facilities have an establishment of about 13,000 of which only about 7,760 is filled (60% filled) only about 37% of these are health professionals

Background

CHAM is a major partner of the ministry Health in provision of health services in Malawi

In addition CHAM trains health care workers in its 10 training colleges producing about 80% of middle level nurses in the country

Nine colleges train nurse/midwife technicians and one of these trains medical assistants, clinical officers, and lab technician on top of the nurses.

The tenth college provides upgrading training in mental health and also some counseling courses

HR Situation in Malawi

HR crisis experienced in the health sector has not spared Malawi as a nation and CHAM facilities have been affected even had due to their locality among other factors.

The nursing cadres have the critical shortages which includes the nurse tutors in the colleges

CHAM/GoM Partnership

MOH subverts salaries for all CHAM hospitals based on an MOU signed in 2002 as basis for support. Also based on an agreed fixed establishment for each size of health facility, which has seen CHAM facilities getting full govt. pay package by 2004.

SWAP was developed in 2004, separate MOU was signed with funding partners (NORAD,DFID,GTZ e.t.c). CHAM got key role on the human resource development component. (within MOH six year emergency training plan)

Towards 2005, CHAM developed and implemented a five year comprehensive HR plan responding to the crisis.

Government and some development partners agreed to finance the plan.

The plan aimed at strengthening the capacity of the colleges in order to train increased number s of middle level qualified health personnel. The target was to produce 500 nurses every year thus 2500 by 2010 and 140 other clinicians i.e 700 clinicians

Partnership…..

HR plan focused on infrastructure expansion, staff motivation and retention, full student scholarships, teaching and learning materials, student transport, and improving quality of nursing education.

CHAM collaborates with Malawi government and development partners for the success of the plan.

The plan estimated at $31.6m as follows; SWAP(mainly DFID, NORAD) funds $2.08m covering increased operational costs, Norwegian Church Aid (NCA) $6.9m, CORDAID Eur400,00) covering infrastructure improvement, GoM $18.3m for student and staff grants.

Some discrete funds from GTZ support tutor incentives and NCA covering for the quality of training.

The proprietors contribution in the plan include free housing accommodation, medical care, free water, electricity, and other social amenities etc.

Retention strategies

DFID 52% top up for health professionals across the board (CHAM/GoM facilities)

GTZ tutor incentives attracted more tutors to the colleges GoM seconding tutors to CHAM colleges for a 2 year contract. Tutor upgrading training programmes (Masters Degree scholarship

after working for a specified period) Free Staff transport to town for shopping at least once a month. Promising non monetary incentives (Package developed and already

approved just awaiting funding by MOF) yet to be implemented jointly by GoM and CHAM.

Review of college establishment and subsequent Promotion of tutors (Position of college Principal at P7 introduced in 2005, and Principal tutor at P8 enabled retention of long serving senior tutors that had been upgraded under the plan.

Achievements

Infrastructure development and improvement programme enabled construction of new and re-arrangement of old structures to increase student bed and learning space and tutor accommodation.

Generally improved quality of training with the improved support structures e.g libraries, skills labs, kitchen and dinning rooms. Figure 1 is summary of planned structures against achievement as of August 2008.

Progress on infrastructure plans

0

200

400

600

800

1000

1200

1400

1600

Planned Completed In progress Gap

Bed space

Staff houses

Other structures

Achievements….. Student capacity has been noted doubling and tripling in terms of

intake and graduates in all cadres in the colleges with remarkable stride to achieve the national targets see graph.

* Change of curriculum in 2004 affected number of graduates in 200

0200400600800

2005 2006* 2007 2008

Intake

graduates

Annual targets

Achievements

A small increase (26%) has been observed in the level of teaching staff for nursing programmes in CHAM colleges. The increase is attributed to improved accommodation available in the colleges and the monetary incentives maintained under the GTZ.

67% of the tutors in CHAM are on government secondment and are attracted and retained by the monetary incentives.

Summary of staffing levels

0

10

20

30

40

50

60

70

2003 2004 2005 2006 2007 2008

tutors

Clinical instructors

Achievements

A few Staff development interventions have been achieved within the plan due to in availability funding allocation for this. Funds were sourced external to the plan that helped to do a few things that included teaching and capacity building workshops, tutor exchange visits with the Norwegian colleges, upgrading courses to BSc, and Masters level, tutor short courses and promotion of tutors

Achievements…..on staff Development

05

101520253035

Tutor upgrade

Bsc

Tutor upgrade

Msc

Short courses

Exchange visits

Promotions P7

Planned in 5 yrs

Achieved to date

Gaps

Achievements……

Through support under the SWAP, DFID funds supported procurement of (9) 32 seat min buses to ease transport of students to clinical area.

Lobby with regulatory bodies saw CHAM have Nurse midwife curriculum upgraded from two year certificate program (without midwifery) to a three year programme with College Diploma and have midwifery skills.

Through NCA and GTZ a number of modern learning materials were procured and distributed to the colleges to strengthen teaching strategies.

CHAM and GoM have agreed to share the graduates in the ratio of 40:60 immediately before graduation the students are posted to a duty station.

Challenges

Budgetary constraints under infrastructure development have constrained funding to meet all the needed essential college infrastructure this has been compounded by fluctuation of costs of building materials.

Inconsistent flow of SWAP funding to cover increased operational costs. Intake was increased in 2006 by adding deck beds in existing hostels and using rental satellite campuses. This increased student capacity in general without increase in sanitary amenities.

Increased intake meant that mother hospitals could not provide adequate space for practical experience other away district hospitals offer practical experience which is expensive in terms of student travel and accommodation

Cont…..

In adequate staffing levels and transport shortages has compromised clinical supervision when students are at district hospitals for practical. In fact teaching staff has not increased at the same rate as student intake. Also up keep of tutors at distant clinical areas is a challenge altogether.

Poor conditions of services especially seconded tutors who usually operate from two homes for the 2 years they are away from normal duty station. In some cases they have been forgotten on issues of career progression in government.

Tuition Fees has remained static since 2004 and the colleges being solely dependent on Government grant are at times on the verge of closing if not funded on time.

Cont…

Sharing of graduates has its own problems in the sense that not all report to their duty station. Some sneak out and join other employers other than CHAM or Government mechanism to control this is not available yet.

Conclusion

The project is on course but running at deficit of $4m Depends entirely on the strong partnership and collaboration with

the GoM and the other funding partners. The face of the CHAM colleges in general (infrastructure

improvement) has been lifted up having renovated old structures and built new ones.

Increased student capacity and out put of the nurse midwifes Tutors remain a scarce resource and need to be retained once

attracted Provision of monetary incentives is not conducive for long term

problem solving however it has been found to be an interim alternative in Malawi.

Maintaining required numbers of staff is key to improving the quality of training

New college infrastructure

Graduates

2008 Joint graduation

2008 Joint graduation

2008 graduation