Where Have All the Health Workers Gone?Malawi’s Response

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 2yrs5. 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.

ImpactImpactImproved 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

ZIKOMOThank you