Malawi's Emergency Human Resources Plan: a ray of hope?

 In June 2004, a six-year "Emergency Human Resources Plan" (EHRP) was launched by the government of Malawi, some elements of which had been implemented as early as 2002. Political mobilisation of a wide range of actors - particularly the UK Department for International Development and the Global Fund to Fight AIDS, TB and Malaria - emboldened the government to request financial support for several measures to address the human resource shortages. These include: funds for increasing salaries for 11 categories of health workers, repatriation of professionals that had left the country, recruitment of retired workers, incentives for rural posts such as improvements in staff housing, and strengthening of training capacity. As a stop-gap measure, it also includes funding for recruitment of foreign doctors and nurse-trainers. This plan is significant because it is the first time that donors have provided substantial, pooled funding for a national effort to address the crisis in human resources for health. The taboo against strengthening human resources through support for salaries and other recurrent costs - on the grounds that such support will not be "sustainable" - has been broken.6 Another reason the EHRP is significant is that the government reached a special agreement with the International Monetary Fund (IMF) and other institutions to increase salaries. This health exception allowed salary increases for health workers without requiring changes for the entire civil service wage bill. Although progress has been slow, there are indications that some elements of the plan are beginning to stimulate change. For example, the programme has slowed migration abroad, from 86 health workers in 2005 to 30 in 2006. While it is not possible to tie specific strategies to results, a series of measures have started to stem the tide, including improved salaries, benefits, and working conditions, and increased access to training. In addition, the UK government signed a code of conduct in which it agreed to stop recruiting in countries with critical health care crises, although this is not always respected by private agencies. National output of nurses went up from 296 in 2002 to 475 in 2005. Intake for doctors in training went from 16 in 2002 to 53 in 2005. Salaries increased by an average of 30%, but since the starting salary was so low, health workers do not consider this change to be adequate. Although the Malawi initiative is promising, it has not been without problems. Disagreement between the government and the Global Fund on how to channel funds has stalled Fund disbursements. Furthermore, despite some progress, national plans and funding opportunities are not being clearly communicated in districts. In practice this has meant that local managers are sometimes not aware of, or do not know how to access, some elements of the programme and so are not able to take advantage of it. For example, although money has been allocated for housing in Thyolo, no staff houses have been built or renovated. In addition, retired nurses who have been attracted to return to the workforce are having trouble getting contracts and payment due to administrative delays. Unless these issues are addressed, it is unlikely that the goal of putting another 85,000 people on ART by the end of 2008 will be met.