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Invigorating the Health-Care Work Force to Combat HIV/AIDS in Malawi
 HIV/AIDS is increasing demand for vital health services at the same time that it is taking the lives of health providers whose services are more critical than ever. An estimated 44 percent of nurses are HIV positive in southern Africa.
Throughout Malawi, 40 percent of Ministry of Health (MOH) positions are vacant. At Lilongwe Central, an 830-bed hospital, 532 nurses are needed, yet only 182 are available to provide health services to patients. Overworked and exhausted health workers leave sick patients with long waits for basic care, or are rushed when providing services. Inadequate compensation, benefits and incentives, a shortage of qualified instructors in teaching institutions, and an exodus of skilled workers to other countries have all contributed to the shortage of health workers. More recently,high mortality rates among health workers, especially due to HIV infection and AIDS, has added a disastrous dimension to the existing shortage.
HIV/AIDS spreads rapidly in Malawi, where the public health system was initially unprepared to launch a counterattack on the epidemic. Throughout the 1980s and 1990s, the country lacked widespread voluntary counseling and testing (VCT) services, and the disease spread rapidly. Even more problematic than the lack of a measured public health response was a general misunderstanding and pervasive stigma about HIV/AIDS – often viewed as a 'rich man's disease' or even caused by witchcraft. In Malawi today, nearly 2 million people are infected with HIV/AIDS. The disease knows no socioeconomic boundaries; it affects all groups, including health-care workers,who are desperately needed to care for the sick and combat the spread of the epidemic.
To address the risks to the health of health-care workers and the crisis caused by the alarming drop in their numbers, the government of Malawi developed a human capacity development (HCD) strategy to strengthen management systems and support HIV/AIDS services. The strategy focuses on the recruitment,training, deployment, motivation and retention of health workers to help meet the medium- as well as long-term objectives of the health sector. The MOH is working with Management Sciences for Health (MSH) on a Malawi program, funded by the U.S. Agency for International Development (USAID). The program provides training and other human resource management and capacity development assistance to implement this strategy in eight of Malawi's 28 districts, covering 40 percent of the population. To illustrate how this strategy was implemented, it is useful to review MSH's work in mitigating the impact of HIV/AIDS in Malawi.
Strengthening Human Capacity
VCT centers have the potential to provide HIV-positive people with informationon how to manage their condition, avoid infecting others and plan for the future. Therefore, the National AIDS Commission (NAC) in Malawi identified VCT as a strategy for containing the spread of new HIV infections and reversing the epidemic. However, an assessment of the VCT services in eight MOH/MSH target districts revealed poor VCT services, largely because of the limited number of available counselors, inadequate organizational structure of the sites, counselors who were not trained in testing, and HIV test results that took three to five days because testing was done off site in laboratories.
In response, MOH/MSH Malawi recruited and trained 16 full-time VCT counselors (two for each focus district). Equipment and furniture was provided to the VCT centers in all the eight focus districts, enabling counselors to perform rapid HIV testing and counseling in the same room. The wait time for HIV/AIDS test results decreased from several days to less than 15minutes.
This support assisted in increasing the number of counselors dedicated to routine counseling and testing as well as provided an improved environment in which to offer counseling and testing. The number of clients increased rapidly from about 6,000 in the last quarter of 2004, when the dedicated counselors became active to more than 13,000 during the first quarter of 2005 following the reorganization and strengthening of VCT services. During this time, an intervention was implemented aimed at integrating tuberculosis (TB) and HIV services at VCT sites with the provision of counseling and testing to all TB patients and all HIV-positive TB patients being offered cotrimoxazole prophylaxis. During the first quarter of 2005, approximately 60 percent of all TB patients were tested for HIV and a large proportion was subsequently put on prophylactic treatment.
The initial inputs for this initiative were supported by a series of interventions aimed at strengthening current human resource management activities. The MOH/MSH Malawi Program assisted each district health office and hospital by reviewing its vision, mission statement, goals and strategies. Job descriptions were updated, and staff roles and responsibilities were reviewed. Individual and group work plans were prepared and implemented, and inservice training on leadership skills and team development were provided to help health managers identify priority management areas. This process contributed to the implementation of HCD interventions in Malawi aimed at easing the burden caused by the shortage of health workers.
Training has emerged as a very strong motivating factor in the retention of health-care workers. By creating 'counseling' as a career option, the offer of employment through MSH as full-time counselors is also a very strong motivating factor. The monthly and quarterly meetings held for counselors in all eight focus districts provide for regular information and idea exchange among health workers. Quarterly support visits are also gaining prominence as managers are able to provide leadership to face challenges and achieve results.
While final evaluations of the intervention results have not yet been conducted,indications already suggest a positive impact on the health-care delivery system. Limitations to salary scales and working conditions still exist, but there has been a reduction in the exodus of health workers in each district,with more trained and motivated health workers at district and sub-district levels, revitalized management and other systems, and increased efficiency and effectiveness in the referral systems within the district.
For more information about MSH's HCD work and its program in Malawi, visit http://www.msh.org
Critical Components Of An HCD Strategy
While there are common human resource (HR) challenges across countries, each country requires a unique human capacity development strategy reflecting its own context, resources, and constraints. MSH's approach to HR challenges are grounded in the Human Capacity Development Framework, developed by MSH and other collaborating agencies (Family Health International, JHPIEGO and the Synergy Project) for the USAID office of HIV/AIDS.
The HCD Framework provides an integrated, comprehensive pathway to finding sustainable solutions to HCD challenges. It presents the four critical components of any human capacity development strategy: (1) policy and financial requirements; (2) human resource management; (3) partnerships; and (4) leadership.
These elements are to a great extent expressed through MSH's support to the MOH in Malawi. Financial support provided through MSH has contributed to an increased pool of VCT counselors dedicated to these activities. It is expected that these counselors will be absorbed into the MOH or local nongovernmental organizations when the financial support from MSH comes to an end. A supportive policy environment has now been developed allowing counselors to do rapid testing onsite thereby strengthening the role of lay counselors in counseling and testing and in streamlining the provision of services. Improved human resource management has contributed to the effective deployment of counselors together with the development of effective supervision and mentoring. Rosters are now placed at VCT sites, thereby ensuring that counselors are available at all times and there is improved supervision of counselors.
The partnership between the MOH of Malawi and USAID/MSH has contributed to the availability of more counselors and improved quality of services through effective technical support. The leadership of the MOH in working with NGO's and other groups has allowed the effective deployment and support of counselors.
Retaining Staff in the Kasungu District
Difficulties in Retaining Staff
"...It's difficult to meet the needs of the patients because we don't have sufficient staff, training or equipment. Patients have to wait several hours to get their HIV test results. Many leave and have to come back the next day; a few never return for their results," said Dr. T. Thafatatha, the district health officer of Kasungu District Hospital. Staff in the Kasungu District Hospital tried to provide the best HIV/AIDS services related to prevention of mother to child transmission (PMTCT), VCT and the provision of antiretrovirals (ARVs), but they received numerous patients
each day and were overworked and untrained. This problem of limited trained staff was compounded by the fact that several health workers were HIV-positive and often out sick.
Encouraging Staff Development
Understanding that good human resource management is essential to retaining staff and maintaining a high overall level of performance, MOH/MSH Malawi recruited and trained two full-time VCT counselors for the hospital to supplement available staff. In addition, counselors were equipped with new tools and furniture that enabled them to perform rapid testing and counseling in the same room. This has increased efficiency and availability of CT services to clients in the district. Although limitations related to salary scales and working conditions still
exist, there has been a reduction in the exodus of health workers to other health providers in this district.
Caring for and Supporting HIV-Positive Staff
With a high HIV transmission rate of 12 percent, one of the highest in the country, nearly 66,000 people in Kasungu are infected with the disease. The fear of discrimination, stigmatization, and the fact that there are only seven VCT facilities in the Kasungu District are major issues that fuel the spread of the disease by hampering more people from seeking to know their HIV status.
To reduce transmission rates and educate the community about HIV, the Kasungu District Hospital and health center drama groups, in partnership with community-based care groups in 112 villages, host community HIV/AIDS sensitization sessions where HIV-positive hospital staff often share their testimony. This not only raises awareness about the disease, but acts as a form of support for the infected staff. Access to ARVs has also been extended to health workers who have tested HIV positive and have developed AIDS. Keeping HIV-positive staff mentally and physically healthy has led to a decrease in the death rate of district health workers.
The demand for VCT and ARVs is increasing in Kasungu now that the community is becoming educated about HIV transmission. However, the numbers of counselors available are still small and funding for training remains inadequate.
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