SMP - Douglas Lungu
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Transcript of SMP - Douglas Lungu
Challenges of Health Delivery In Malawi
Douglas Lungu FCS(SA)DDaeyang Luke Hospital
Lilongwe
Outline
• Background Health Indicators• Constraints to Health Care Delivery• A view from the valley • Issues for consideration.
Immunization % fully immunized (1-year-old children) BCG 84 DPT3 84 Polio3 74 Measles 83 % of routine EPI vaccines financed by government 2 . Water and Sanitation % of population with access to % of population with access to safe water adequate sanitation Water - total 57 Sanitation - Total 76 Water - Urban 95 Sanitation - Urban 96 Water - Rural 44 Sanitation - Rural 70
Malawi 2000 and 2004
Safe water – total 2004 = 63% sanitation 2004 – 84%
Health expenditure
Total per capita expenditure $12.4– Malawi Government $3.1– Donors $3.7– Employers $2.3– Households $3.2
EHP proposal $17.3 Macro-economics Commission $34
Nursing College
NURSING COLLEGE
Human resources
Staff number ratio to population number ratio to populationCommunity level
Health serveillance assistant 6,474 1,815 11,750 1,000 Health Centre 436 26,950 569 20,650
Medical assistant 399 29,449 569 20,661 Midwives 1,368 8,589 1,706 6,887 Others 3,588 3,275 3,981 2,952
District hospital 27 435,185 27 435,185 District health officer 20 587,500 27 435,185 District medical officer - 81 145,062 Clinical officer 238 49,370 270 43,519 District nursing officer 11 1,068,182 27 435,185 Nurses 283 41,519 3,186 3,688 Hospital administrator staff 11 1,068,182 54 217,593 Technical staff 122 96,311 378 31,085 Accounts staff 34 345,588 243 48,354 Environmental health staff 113 103,982 1,242 9,461 Community nurses 105 111,905 540 21,759 Patient attendant 890 13,202 2,160 5,440 Others 1,012 11,611 2,106 5,579
Total 15,131 777 28,916 406
existing plannedHuman resources for Essential Health Package
Human Resources - availabilityNkhotakota Nsanje Rumphi
HC Hospitals HC Hospitals HC Hospitals
Physicians 50% 50% n/a 33% n/a 33%
Clinical Officers
67% 100% n/a 52% 100% 37%
Medical Assistants
91% 100% 67% 73% 68% 65%
Regist. Nurses
56% 88% n/a 33% n/a 29%
Enr. Nurses
56% 78% 53% 56% 41% 60%
Overall , 57% of physicians’, 32% of CO’, 27% of MA’, 61% of Registered nurses and 52% of Enrolled nurses’ positions were vacant.
Human Resources - absences
Physicians (n=10)s
CO (n=52)(
MA (n=66)M Reg. Nurse (n=27)(
Enr. Nurse (n=230)(
Total (n=385)(
Leave 2.0 (3%)2 3.8 (5%)3 2.6 (4%)2 2.6 (4%)2 2.4 (3%)2 2.6 (4%)2
Training 0.9 (1%)0 3.1 (4%)3 4.1 (6%)4 6.6 (9%)6 3.2 (5%)3 3.5 (5%)3
Meetings 3.7 (5%)3 3.0 (4%)3 1.9 (3%)1 2.3 (3%)2 1.1 (2%)1 1.6 (2%)1
Sick leave 0.2 (0.3%)0 0.5 (1%)0 0.9 (1%)0 2.9 (4%)2 0.9 (1%)0 1.0 (1%)1
Relief duties
0.5 (1%)0 2.2 (3%)2 2.2 (3%)2 1.6 (2%)1 1.6 (2%)1 1.8 (3%)1
Total 7.3 (10%)7 12.5 (18%)1 11.7 (17%)1 16.0 (23%)1 9.3 (13%)9 10.5 (15%)1
Days absent over last 3 months; in brackets percentage of working days absent (3 months = 71 working days at 5.5 working days p. week).
Human Resources – absences II• Between all cadres, only 5% of working time
is spent on training. However, most of this training is attended by registered nurses and MA – while enrolled nurses, who form the bulk of the health workforce, get little training in comparison.
• Training and meetings together account for most absences among all levels of health workers (training alone accounts for 41% of all absences!).
Human Resources – absences III
• DHMTs acknowledged the very high amount of training. During our visits in all 3 districts several trainings happened in the meantime.
• Many of these trainings are not requested by the DHMTs; however, they also feel unable to decline participation. Some acknowledged that there are monetary incentives driving the attendance of trainings and meetings.
• Also at central level, the “burden” of trainings is well known, although voices differed over how much influence DHTMs would have over attendance.
Human Resources – knowledge Nkhotakota Nsanje Rumphi Total
Malaria in children <5 assessment
HC (n=39)(
Hosp (n=10)(
HC (n=24)(
Hosp (n=12)(
HC (n=30)(
Hosp (n=14)( (n=129)(
fever 97% 100% 100% 100% 100% 100% 99%
anaemia 67% 100% 75% 83% 77% 71% 75%
Blood film (BF)B 92% 100% 100% 92% 97% 100% 96%Acute respiratory tract infections (ARI) assessment
fever 62% 60% 67% 83% 67% 71% 67%
respiratory rate 44% 50% 63% 75% 40% 50% 50%
chest movements 67% 90% 71% 83% 70% 50% 70%
Opportunistic Infections (OI) assessment: Zoster
blisters 87% 100% 79% 100% 77% 93% 86%
Dermatome distribution of symptoms 28% 40% 50% 92% 37% 71% 46%
History of VCT 49% 90% 58% 58% 70% 86% 64%
Human Resources – knowledge II Maternal Health (MH) Nkhotakota Nsanje Rumphi Total
HC (n=23)(
Hosp (n=3)(
HC (n=19)(
Hosp (n=9)(
HC (n=18)(
Hosp (n=13)( (n=85)(
Post-partum haemorrhage (PPH)P
bleeding profusely 91% 100% 63% 44% 39% 46% 62%
vital signs 52% 100% 68% 67% 39% 54% 56%
check for contracted uterus 52% 67% 63% 78% 59% 62% 61%
inspect for tears 65% 67% 74% 67% 72% 75% 70%
Maternal Health (MH) assessment: Eclampsia
vital signs/blood pressure 87% 100% 79% 89% 72% 69% 80%
general maternal condition 13% 33% 5% 11% 22% 8% 13%
check urine for protein 48% 67% 58% 100% 56% 62% 60%
Working and living conditions
• The majority of health workers would prefer to work at a different facility (hc=71%, hospitals=54%).
• Some staff members in rural settings highlighted their fear of encountering severe conditions and death in light of not being able to perform adequate treatment.
• 34% of staff said they had felt a change in their salary during the preceding 2 years. In meetings with DHMTs this was considered not true but the increase was offset by tax and price increases.
Working and living conditions II
• Commonest complaints were work load, lack of transport for referrals and lack of electricity, water, communication and maintenance.
• 49% of staff were happy with their housing, small sizes and lack of maintenance were the most frequently mentioned challenges.
• DHMTs highlighted lack of funds and lack of transport as huge challenges.
• But improvements, especially to some facilities and housing was also noted.
Karonga ANC/Community study
Neglected Disease
• The fight against HIV is slacking• The success of ARV treatment is
threatening to derail prevention efforts.• There is need to always programme
HIV/AIDS activities in all our interventions.
Winston Churchill
‘Once in a while you will stumble upon the truth but most of us manage to pick ourselves up and hurry along as if nothing had happened’
Access to health care
Measuring equity of supply of health care
Lorenz curve components
0
5
10
15
20
25
30
35
Poverty Quintile
% o
f to
tal
va
ria
ble
health needs (as a % oftotal pop health needs)
30 25 20 15 10
Actual health care supply(as a % of total healthsupply
15 17 20 23 25
very poor poor average rich very rich
Home based Care Group
Results 1: Current geographical accessibility
53 % of population is within 5km of a health facility
83% are within 8 kmAverage distance to the nearest health
facility: 5.3 kmAverage walking time: 1 hour 17
minutes
Proportion of population over 8 km from a health facility per district
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%
Kasungu
Malawi
Chiradzulu
Average travel time to a closest health facility per district
0 20 40 60 80 100 120 140
Kasungu
Malawi
Chiradzulu
Result 2-1: Kasungu District
Population: 490,000 Population density: 65/km2
The worst geographical access– Average distance: 8 km– 1 facility per 31000 people
Existing facility locations
Optimal facility locations
Results 2-2: Kasungu District
Current situation– 16 health facilities– Average distance:
8km– One facility per
31000 people
Optimal locations– 14 existing facilities
remained open– 40 additional facilities
required– Total 54 facilities– Average distance:
3.6km– One facility per 9400
people
Results 2-3: Chiradzulu district
Population: 296,000 Population density: 307/km2
The best access district:– Average distance: 3.6km– One facility per 25,000
Existing facility locations
Optimal facility locations
Results 2-4: Chiradzulu district
Current situation– 12 health facilities– Average distance:
3.7km– One facility per
25000 people
Optimal locations– 5 existing facilities
remained open– 4 additional facilities
required– Total 9 facilities– Average distance:
3.5km– One facility per
32800 people
Challenges
Scarce resources in terms of skilled staff and equipment hence needs concentrated facilities. Not dispersed across small facilities
To provide care rather than cure. Care requires people rather than equipment, generalists rather than specialists. Access is more important
Access to Health a case for mobile clinics
• Mobile clinics have always been used.• There is need to reconsider• The manner in which they are deployed
will much depend on the local situation• May range from a simple boat to
sophisticated units.• These may be easier interventions and
much more basic.• Support to static units.
Access to Health a case for mobile clinics
• Currently – growth monitoring clinics ANC/U5C
• No organised treatment• Specialist monthly visits to the districts• Not predictable so not reliable• Consider specifically for personnel
Choosing a primary care package of health services
Important disease – burden of disease– Premature mortality– Major morbidity
Good intervention– Cheap– Acceptable– Practical– Possible
View from the Valley
• The effort to improve the HR problem will need to be intensified
• This should be both in numbers and quality• Senior health personnel will have to be at
the district. (Family Health Specialist)t• Access to health for the rural will have to
be improved. Static or mobile?• A big eye on HIV • Monitoring and Evaluation / Accountability
Implementation
Who?
How?
When?
Implementation - who
Implementation - how
We look further because we stand on the shoulders
of Giants
Dr David Livingstone
Thank you!