Where Have All the Health Workers Gone? Malawi’s Response
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Transcript of Where Have All the Health Workers Gone? Malawi’s Response
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Where Have All the Health Workers Gone?Malawi’s Response
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Presentation OutlinePresentation Outline
Malawi’s Response
Challenges and Trends
Lessons Emerging
Impact and Sustainability
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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
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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
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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”
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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
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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
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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.
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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.
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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
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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
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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.
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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
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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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ZIKOMOThank you