Malawi: Despite new types of health workers, demand still outstrips supply

Population: 13 million[ii] Life expectancy: 39.7 years Adult HIV prevalence: 14.1% No. of people with HIV/AIDS: 940,000 No. of people in need of ART: 170,000 No. of people initiated on ART: 85,000 Treatment deficit: 85,000 Proportion of national budget spent on health: 9.1% Malawi is a mostly rural country where more than 65% of the population lives below the poverty line. MSF HIV/AIDS treatment programmes MSF supports HIV/AIDS care in Thyolo district (population 575,000) a rural area in the south of Malawi, in two hospitals and 17 health centres. ART is almost entirely managed by clinical officers and nurses, with support from hundreds of community volunteers, many of whom are people living with HIV/AIDS. By the end of 2006, 7,216 patients had started ART across all facilities in Thyolo, with 5,727 (79%) still in care, constituting a near doubling from the previous year. Approximately 11,500 people were estimated to need ART in 2006. Severe staff shortages in Thyolo cause a constant 'replacement' scramble and absences due to illness, family commitments, or trainings put a heavy strain on remaining staff. Fatigue and burn-out are common, as existing staff often do double shifts or forego holidays to replace colleagues. MSF has another project in neighbouring Chiradzulu district (population 280,000), where ART was first provided in 2001 at the district hospital. Since 2002 mobile teams have been deployed to rural clinics every two weeks to provide ART and follow-up for stable patients. Since the programme's inception, 10,353 people have been initiated on ART, 6,710 of whom (64%) are still in care. MSF is currently training Ministry of Health nurses to manage stable patients, hiring additional staff for clinics to help with non-HIV workload, and piloting further decentralisation through the deployment of community-based lay workers. These are primarily people on ART who dispense ARVs to stable patients in villages.[iii] Staff shortages are similarly severe in Chiradzulu and are worsening by the day. For example, in 2006, there were 50 nurses working at the district hospital; this year, that number has dropped to 28. National human resource situation About half of the 165 medical doctors working in Malawi are in central hospitals in urban areas, leaving severe shortages in rural areas, where nurses are also lacking.5 The vacancy rate for nurses in rural areas is 60%.[iv] To compensate for the lack of doctors, Malawi relies on clinical officers and medical assistants. However, due to shortages across the spectrum of health staff, the government has created a new cadre, health surveillance assistants (HSAs), who receive 10 weeks of training and are responsible for multiple tasks including: immunisation, dispensing of essential drugs, and, more recently, HIV testing and counselling. HSAs could potentially dispense ARVs but national policy is ambiguous about whether this is permitted. Adding additional tasks to HSAs may be difficult considering the allocation of one HSA per 1,000 inhabitants did not take HIV-related tasks into account and nowhere near this number of HSAs are in place: only half of the 580 HSA posts in Thyolo and even fewer of the posts in Chiradzulu are filled. The lack of health workers partly results from people leaving for 'greener pastures,' taking higher-paying jobs in the private sector or overseas. There is also an internal ‘brain drain' from the public sector to non-governmental organizations (NGOs) and other private non-profit employers, such as the Christian Health Association of Malawi. The current basic salary of a public sector nurse remains low, at roughly 12,000 kwachas per month ($US 87), forcing many to supplement their income with other jobs or additional shifts.