Shortages of healthcare workers defeats Aids initiative

Correspondent OWEN NYAKA explores the challenges standing in the way of achieving zero-Aids deaths in Malawi.

Malawi’s health sector is grappling with a serious lack of trained healthcare personnel who can have an impact on its Global Fund-supported programming to enrol a greater number of HIV-positive Malawians on antiretroviral therapy (ART).

Global Fund support to the Malawian health sector for ARV purchases began in June 2004. Prior to that Round 1 application, only nine public sector facilities offered ART, reaching just 3 000 people—about a percent of the national need.

According to UNAids figures, Malawi has a generalised HIV epidemic with an estimated HIV prevalence of 10 percent. About 910 000 people are living with HIV and 44 000 Aids-related deaths were reported in 2011.

With donor support, Malawi has scaled-up its ART services. As of June 2011, 449 clinics were reaching 276 987 (67 percent) out of the 411 574 Malawians in need of treatment.

But those successes are under threat because of the acute shortage of trained health personnel in the public sector. World Health Organisation (WHO) recommendations encourage a ratio of seven healthcare workers for every 1 000 patients on ART. As of 2010, Malawi’s ratio was about half: 3.54 health workers per 1 000 ART patients. Malawi has only two doctors and 37 nurses and midwives for every 100 000 people.

Low pay and poor working conditions, particularly in remote areas, are some of the factors inhibiting the country’s ability to reach the recommended ratios. However, the sector has also been badly hit by the Aids epidemic.

“The shortage of health workers has an impact on healthcare delivery,” said Adrian Chikumbe, spokesperson for the Ministry of Health’s HIV prevention and behaviour change said. “Government is making efforts to increase their numbers, and we have seen significant improvements.”

With one of the world’s lowest ratios of healthcare professionals per population and low laboratory capacity, Malawi has relied on a “public health approach” to ART scale-up.

With support from the Global Fund, the ministry has developed national ART guidelines that provide healthcare workers with a standard approach to patient assessment, initiation and reporting. Almost all patients are given the same low-cost, fixed-dose combination first-line therapy. Due to the shortage of physicians, lower cadres of healthcare workers provide care to people living with HIV at most health facilities.

Of the more than $777 million in Global Fund grants signed for Malawi since 2002, some $44 million was allocated for health system strengthening.

To address the staff shortage, the Global Fund and Department for International Development (DfID) pooled resources to initiate the Emergency Human Resources Programme (EHRP) in 2005. The six-year, $272-million programme provided a 52 percent salary increase for all health workers, an expansion of pre-service training and recruitment of expatriate volunteer doctors and nurses. The EHRP also included incentives to attract healthcare workers to underserved regions of the country.

According to an analysis of the EHRP by Management Sciences for Health (MSH), the salary ‘top-ups’ helped stem the flight of healthcare workers from the public sector. The expanded pre-service training boosted the number of health professionals trained annually to 1 000 in 2008 from just 400 in 2004.

Despite this success, however, Malawi is still far from achieving the right ratio of healthcare professionals to patients to effectively confront HIV with a full slate of prevention, treatment and care activities.

According to the District Implementation Plan (DIP) for Lilongwe for the 2011-12 financial year, the doctor-to-patient ratio is 1:110 195, with staff retention remaining a serious challenge.

Malawi is still operating at only around one-third of its total need for health workers. According to the Nurses and Midwives Council of Malawi, the country has produced less than 10 000 nurses/midwives since 1947, yet the national population has almost quadrupled since then.

Lost tax revenues

Malawi has lost more than $43 million in revenue between 2009 and 2014, from a single company-the Australian mining company Paladin.

The money has been lost through a combination of harmful tax incentives from the Malawian government, and tax planning using treaty shopping by Paladin.

ActionAid’s conservative estimates say while Paladin has not broken the law by avoiding this tax in Malawi, this tax revenue could have paid for 431 000 annual HIV and Aids treatments; or 17 000 annual nurse salaries or 8 500 annual doctors salaries in the health sector.

According to UNAids, 10.3 percent of Malawi’s population between 15-49 years old is living with HIV. While government is reporting a massive Aids funding gap, the $43.16 million tax revenue could boost the country’s health sector.

First line Aids and HIV treatment costs around $100 per person a year, meaning that the money lost through Paladin’s tax affairs could have paid for more than 431 000 annual HIV and Aids treatments. In Malawi, there are only 0.3 nurses and midwives per 1 000 inhabitants.

This can be compared to the Netherlands, where the ratio is 8.4 nurses and midwives per 1 000 inhabitants, and Australia where the ratio is 10.6 nurses and midwives per 1 000 inhabitants.

Meanwhile, the density of doctors in Malawi, according to the WHO’s latest available data, is 0.019 doctors per 1,000 inhabitants—or roughly 300 doctors for a population of over 16 million—in 2009.

Constraints faced by nurses and midwives

Colleges of nursing in the country are facing challenges related to funding, characterised by intermittent funding, college closures and uncertain academic calendars. Yet Malawi urgently needs more nurses and health workers to fill the high vacancies in hospitals and health centres.

“I have been working as a nurse since 1971 and what we are seeing is an emergency. There are too many patients for too few clinicians and nurses, and the pressure is too much. Look at this overcrowded ward, look at all these patients!

“Tonight there will be one nurse to look after all of them. What kind of nursing is this? How can we ever give patients the care they need? If we are to solve this problem we will need to have many more health workers, better conditions of service, better training and incentives. Otherwise nothing will change!” Christian Chingi, a Nurse Coordinator with MSF Malawi is quoted in the Royal Society of Tropical Medicine and Hygiene Journal.

National Organisation of Nurses and Midwives (Nonm), executive director Harriet Kapyepye concurs with Chingi saying, “Salaries and incentives including locum, particularly for those working in rural areas, continue to be insufficient and working conditions tough, with high patient numbers and scarcity of equipment and drugs.”

Locum—which is extra-hours worked by nurses and midwives—has been used as a stop-gap measure for provision of health services due to healthcare workers shortage. However, the rising cost of living and transport costs incurred calls for increase in the rate of locum per extra day/night shift worked by nurses and midwives.

On the other hand, most college students live and learn in poor conditions and have poor of meals. Furthermore, colleges can hardly manage to provide immunisations to students against Hepatitis B virus.

These challenges have not spared students on clinical practice, who lack protective wear such as gloves.

“In our placements, we are in the children’s ward, general ward and also the maternity department where we assist women in labour as well as those that come for family planning or postnatal care.

“So you can see that in all these areas, we are really doing our best despite the constraints,” Kapyepye said.

Insufficient human resource

The Clinton Health Access Initiative says if all nurse training institutions doubled their current training capacity by 2016, Malawi’s staffing gap for nurses could be eliminated by 2019, costing $27.5 million for training institution capacity over a five year period.

Recently, Malawi College of Health Sciences (MCHS) has been hit with closures and outstanding debts, Mzuzu University scholarships for nursing and midwifery students and Christian Health Association of Malawi (Cham) nursing colleges have been hit with closures and outstanding debts, hence nurses and midwives deficit would remain a big constraint.

The funding gap for tuition fees in the 2009-2010 intake resulted in only 392 students graduating from MCHS and 19 students from Cham collages in 2012. This is the lowest number in five years creating the risk that Malawi’s lack of health staff could push its health system back into an emergency state.

There are 36.8 nurses per 100 000 population in Malawi against the WHO recommendation of 100 per 100 000.

In 2009, only 56 percent of health centres in Malawi met minimal staffing requirements of two nurses, two medical assistants and an environmental health officer to deliver the minimum essential health package.

Although HIV prevalence is steadily decreasing in Malawi, patient numbers are growing as more people access ART and need to be retained on treatment. There has been an estimated 25 percent increase in HIV patient numbers since new WHO HIV and Aids treatment guidelines were adopted in 2011. This requires more nurses and other health workers in order to achieve the battle against zero Aids related death.

EGPAF’s initiative

One contribution Elizabeth Glaser Pediatric Aids Foundation (EGPAF) has made is to increase the number of trained healthcare workers. In 2014, EGPAF started a pre-service scholarship programme to address the staffing of hard to reach health facilities in seven districts that frequently face staff shortages.

EGPAF worked with the Ministry of Health and local leaders to identify young people living in the targeted rural communities that could attend training to become nurse midwife technicians and medical assistants and return after training to their own communities.

Country director for EGPAF in Malawi, Nicole Bouno said: “These cadres were targeted as the most useful for primary healthcare in rural areas. EGPAF identified 70 qualified students who began their training in 2014. EGPAF supports the complete package for the students including tuition, room, board, fees, supplies and transportation expenses. This year, 68 students completed their first year of training; two dropped out for other opportunities.”

EGPAF has been working with the students and the four training institutions to follow the progress and encourage the students in their coursework. The medical assistants will graduate in 2016 and the nurse midwife technicians will graduate in 2017.

All the 68 healthcare workers have signed a bond agreement with the Ministry of Health and their communities that they will serve in the rural health facilities for a period commensurate with their training. n