Lessons learned in HIV Funding and HRH Strengthening

1. Lessons learned in HIV Funding and HRH Strengthening Vienna, 17 July 2010 Dr Frank Chimbwandira HIV and AIDS Department Ministry of Health Malawi

2. Malawi: Some Indicators

3. Malawi’s health system is heavily constrained, yet … … the coverage of the programme is higher than what one would expect on the basis of existing capacity By the end of March 2010 over 211,000 people were alive and on (coverage 49% based on CD4 cut-off of 350 cells/mm³) In 2009 over 1.7 million people tested and counselled for HIV ART services provided in 370 health facilities, PMTCT in 650 health facilities and HTC in more than 850 health facilities in the country.

4. Main question How to develop a successful HIV programme without undermining other health services? Or, even better. Could the HIV programme support the development of other health services? • Design of the programme • - Base the programme on realities in the health sector • Address HRH issues • Make optimal use of existing staff (task shifting) • Make health workers a special target in the HIV programme • Advocate for improving HRH improvements

5. Based on realities – a public health approach Reduce complexity of the interventions to the bare minimum!!! Maximise health gain with (very) limited resources standardisation; same approach in Government, mission and private sector (NGOs and PFP) simplification; focus on one regimen for all, make the ART and PMTCT programme independent from laboratory monitoring, simple drug distribution system based on kit system, increase period between visits short training (5 days for ART programme) supervision and monitoring (strong focus and standardised M&E and supervision) shifting and sharing of tasks (Cos, MAs and nurses can initiate ART)

6. Task Shifting Initiation of ART can be done by non-MD clinicians (COs and MAs) and nurses HIV testing and counselling is done by lay-people and health staff with a very short training (3 months - Health Surveillance Assistants - HSAs) Role of HSAs to be further developed and role of Expert patients to be defined.

7. Make health workers a special target group Health workers were special targets in the scale up plan Care of Carer Programme Health workers are part of the population in need • The ART programme needs approximately 800 fte HWs • The ART programme started over 3,000 HWs on ART

8. Address HRH issuesAbsolute shortage of health staff Situation in 2004: 64% vacancies among nurses; 53% vacancies among clinical officers; 85%-100% vacancies among specialists Over half of 29 districts have less than 1.5 nurses per facility, and five districts have less than one 10 districts without a MoH doctor, four districts without any doctor at all

9. Advocate for support for HSS In 2004 the HIV programme strongly rallied to support HRH and ensured the funding for a 6-year Emergency Human Resource Relief Programme (EHRRP) as the number of health workers was the most limiting factor to scale up the programme. The programme (US$ 270 million) was funded by GFATM and DFID. And the main objectives were: • Train more health workers (doubled intake of most cadres) • Top-up of salaries (52%) • Temporary additional staff (VSO, UNV)

10. Achievements of the EHRP

11. Lessons • Government –Donor Collaboration was very critical in the development of EHRP • Commitment • Multi-sectoral involvement was critical

12. Conclusion • HIV funding has contributed to HSS through • Recruitment • Retention • Training • Tuition • Infrastructure

13. Thank you very much!