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

Where Have All the Health Workers Gone? Malawi’s Response. Presentation Outline. Challenges and Trends. Malawi’s Response. Impact and Sustainability. Lessons Emerging. Challenges and Trends. In 2000: 20% of Malawian nurses; 60% of Malawian doctors worked abroad.

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

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

  2. Presentation Outline Challenges and Trends Malawi’s Response Impact and Sustainability Lessons Emerging

  3. Challenges and Trends • 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

  4. Why did this happen? • Insufficient production of health workers • Low 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 conditions • Poor recruitment practices in public sector • Crumbling health system – poor support to staff • Devastating impact of HIV/AIDS

  5. Malawi’s Response • New government in 2004: fiscal discipline • Increased commitment to health sector • In turn: • donor confidence enhanced • increased preparedness to fund recurrent expenditure • momentum for health sector wide “systems approach”

  6. Malawi’s Response:Policy 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 Program • Introduction of LTPM in pre service curricula

  7. Emergency Human Resource Program • Expand training capacity by 50% on average • 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 • Stop-gap external support for critical posts (mostly teaching) - 50 volunteer doctors, nurse tutors per year while Malawians staff trained • MOH HR management support: 3 TA for 2yrs • M&E – linked to SWAp M&E framework

  8. Task 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.

  9. Incentives for Community Workers • HSAs on government payroll • Protective wear; umbrella, raincoats • Bicycles • Community support • Recognition and acknowledgement by influential leaders • Promotion to CBDA supervisor • Performance based awards (Project Specific) • Money for an IGA activity appropriate to the community.

  10. Impact • Improved 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

  11. System Impact: Quality Assurance • Pre and in-service training • Refresher trainings and annual reviews • Field supervisors conduct weekly visits • Monthly/ Quarterly Supervision by program staff • Data management • Linkages and referrals • Concerns on loading too much on HSAs

  12. Impact: Supervision of Community Health workers Levels • Primary level: by Senior CBDA/HSA-1:15 • Secondary level: Service Provider/Program Coordinator • National level: RHU; FBO;NGO; Private Sector Frequency: • Monthly by Primary Supervisor; • Quarterly by secondary supervisor; • National supervisor once per year.

  13. Sustainability • EHRP- modest but promising results • Use of salaried field staff such as HSAs • Volunteer turnover – depends on incentives • All activities steered by central Ministry or Districts for continuity • Streamlined reporting requirements-one LMIS • Standardized guidelines & training materials • Community ownership of volunteers • Strong supervisory system at community level

  14. Emerging Lessons • Political 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 managing • No clear defined role of VHW

  15. ZIKOMO Thank you

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