Challenges of Health Delivery In Malawi

Douglas Lungu FCS(SA)DDaeyang Luke Hospital

Lilongwe

Outline

• Background Health Indicators• Constraints to Health Care Delivery• A view from the valley • Issues for consideration.

Immunization % fully immunized (1-year-old children) BCG 84 DPT3 84 Polio3 74 Measles 83 % of routine EPI vaccines financed by government 2 . Water and Sanitation % of population with access to % of population with access to safe water adequate sanitation Water - total 57 Sanitation - Total 76 Water - Urban 95 Sanitation - Urban 96 Water - Rural 44 Sanitation - Rural 70

Malawi 2000 and 2004

Safe water – total 2004 = 63% sanitation 2004 – 84%

Health expenditure

Total per capita expenditure $12.4– Malawi Government $3.1– Donors $3.7– Employers $2.3– Households $3.2

EHP proposal $17.3 Macro-economics Commission $34

Nursing College

NURSING COLLEGE

Human resources

Staff number ratio to population number ratio to populationCommunity level

Health serveillance assistant 6,474 1,815 11,750 1,000 Health Centre 436 26,950 569 20,650

Medical assistant 399 29,449 569 20,661 Midwives 1,368 8,589 1,706 6,887 Others 3,588 3,275 3,981 2,952

District hospital 27 435,185 27 435,185 District health officer 20 587,500 27 435,185 District medical officer - 81 145,062 Clinical officer 238 49,370 270 43,519 District nursing officer 11 1,068,182 27 435,185 Nurses 283 41,519 3,186 3,688 Hospital administrator staff 11 1,068,182 54 217,593 Technical staff 122 96,311 378 31,085 Accounts staff 34 345,588 243 48,354 Environmental health staff 113 103,982 1,242 9,461 Community nurses 105 111,905 540 21,759 Patient attendant 890 13,202 2,160 5,440 Others 1,012 11,611 2,106 5,579

Total 15,131 777 28,916 406

existing plannedHuman resources for Essential Health Package

Human Resources - availabilityNkhotakota Nsanje Rumphi

HC Hospitals HC Hospitals HC Hospitals

Physicians 50% 50% n/a 33% n/a 33%

Clinical Officers

67% 100% n/a 52% 100% 37%

Medical Assistants

91% 100% 67% 73% 68% 65%

Regist. Nurses

56% 88% n/a 33% n/a 29%

Enr. Nurses

56% 78% 53% 56% 41% 60%

Overall , 57% of physicians’, 32% of CO’, 27% of MA’, 61% of Registered nurses and 52% of Enrolled nurses’ positions were vacant.

Human Resources - absences

Physicians (n=10)s

CO (n=52)(

MA (n=66)M Reg. Nurse (n=27)(

Enr. Nurse (n=230)(

Total (n=385)(

Leave 2.0 (3%)2 3.8 (5%)3 2.6 (4%)2 2.6 (4%)2 2.4 (3%)2 2.6 (4%)2

Training 0.9 (1%)0 3.1 (4%)3 4.1 (6%)4 6.6 (9%)6 3.2 (5%)3 3.5 (5%)3

Meetings 3.7 (5%)3 3.0 (4%)3 1.9 (3%)1 2.3 (3%)2 1.1 (2%)1 1.6 (2%)1

Sick leave 0.2 (0.3%)0 0.5 (1%)0 0.9 (1%)0 2.9 (4%)2 0.9 (1%)0 1.0 (1%)1

Relief duties

0.5 (1%)0 2.2 (3%)2 2.2 (3%)2 1.6 (2%)1 1.6 (2%)1 1.8 (3%)1

Total 7.3 (10%)7 12.5 (18%)1 11.7 (17%)1 16.0 (23%)1 9.3 (13%)9 10.5 (15%)1

Days absent over last 3 months; in brackets percentage of working days absent (3 months = 71 working days at 5.5 working days p. week).

Human Resources – absences II• Between all cadres, only 5% of working time

is spent on training. However, most of this training is attended by registered nurses and MA – while enrolled nurses, who form the bulk of the health workforce, get little training in comparison.

• Training and meetings together account for most absences among all levels of health workers (training alone accounts for 41% of all absences!).

Human Resources – absences III

• DHMTs acknowledged the very high amount of training. During our visits in all 3 districts several trainings happened in the meantime.

• Many of these trainings are not requested by the DHMTs; however, they also feel unable to decline participation. Some acknowledged that there are monetary incentives driving the attendance of trainings and meetings.

• Also at central level, the “burden” of trainings is well known, although voices differed over how much influence DHTMs would have over attendance.

Human Resources – knowledge Nkhotakota Nsanje Rumphi Total

Malaria in children <5 assessment

HC (n=39)(

Hosp (n=10)(

HC (n=24)(

Hosp (n=12)(

HC (n=30)(

Hosp (n=14)( (n=129)(

fever 97% 100% 100% 100% 100% 100% 99%

anaemia 67% 100% 75% 83% 77% 71% 75%

Blood film (BF)B 92% 100% 100% 92% 97% 100% 96%Acute respiratory tract infections (ARI) assessment

fever 62% 60% 67% 83% 67% 71% 67%

respiratory rate 44% 50% 63% 75% 40% 50% 50%

chest movements 67% 90% 71% 83% 70% 50% 70%

Opportunistic Infections (OI) assessment: Zoster

blisters 87% 100% 79% 100% 77% 93% 86%

Dermatome distribution of symptoms 28% 40% 50% 92% 37% 71% 46%

History of VCT 49% 90% 58% 58% 70% 86% 64%

Human Resources – knowledge II Maternal Health (MH) Nkhotakota Nsanje Rumphi Total

HC (n=23)(

Hosp (n=3)(

HC (n=19)(

Hosp (n=9)(

HC (n=18)(

Hosp (n=13)( (n=85)(

Post-partum haemorrhage (PPH)P

bleeding profusely 91% 100% 63% 44% 39% 46% 62%

vital signs 52% 100% 68% 67% 39% 54% 56%

check for contracted uterus 52% 67% 63% 78% 59% 62% 61%

inspect for tears 65% 67% 74% 67% 72% 75% 70%

Maternal Health (MH) assessment: Eclampsia

vital signs/blood pressure 87% 100% 79% 89% 72% 69% 80%

general maternal condition 13% 33% 5% 11% 22% 8% 13%

check urine for protein 48% 67% 58% 100% 56% 62% 60%

Working and living conditions

• The majority of health workers would prefer to work at a different facility (hc=71%, hospitals=54%).

• Some staff members in rural settings highlighted their fear of encountering severe conditions and death in light of not being able to perform adequate treatment.

• 34% of staff said they had felt a change in their salary during the preceding 2 years. In meetings with DHMTs this was considered not true but the increase was offset by tax and price increases.

Working and living conditions II

• Commonest complaints were work load, lack of transport for referrals and lack of electricity, water, communication and maintenance.

• 49% of staff were happy with their housing, small sizes and lack of maintenance were the most frequently mentioned challenges.

• DHMTs highlighted lack of funds and lack of transport as huge challenges.

• But improvements, especially to some facilities and housing was also noted.

Karonga ANC/Community study

Neglected Disease

• The fight against HIV is slacking• The success of ARV treatment is

threatening to derail prevention efforts.• There is need to always programme

HIV/AIDS activities in all our interventions.

Winston Churchill

‘Once in a while you will stumble upon the truth but most of us manage to pick ourselves up and hurry along as if nothing had happened’

Access to health care

Measuring equity of supply of health care

Lorenz curve components

0

5

10

15

20

25

30

35

Poverty Quintile

% o

f to

tal

va

ria

ble

health needs (as a % oftotal pop health needs)

30 25 20 15 10

Actual health care supply(as a % of total healthsupply

15 17 20 23 25

very poor poor average rich very rich

Home based Care Group

Results 1: Current geographical accessibility

53 % of population is within 5km of a health facility

83% are within 8 kmAverage distance to the nearest health

facility: 5.3 kmAverage walking time: 1 hour 17

minutes

Proportion of population over 8 km from a health facility per district

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

Kasungu

Malawi

Chiradzulu

Average travel time to a closest health facility per district

0 20 40 60 80 100 120 140

Kasungu

Malawi

Chiradzulu

Result 2-1: Kasungu District

Population: 490,000 Population density: 65/km2

The worst geographical access– Average distance: 8 km– 1 facility per 31000 people

Existing facility locations

Optimal facility locations

Results 2-2: Kasungu District

Current situation– 16 health facilities– Average distance:

8km– One facility per

31000 people

Optimal locations– 14 existing facilities

remained open– 40 additional facilities

required– Total 54 facilities– Average distance:

3.6km– One facility per 9400

people

Results 2-3: Chiradzulu district

Population: 296,000 Population density: 307/km2

The best access district:– Average distance: 3.6km– One facility per 25,000

Existing facility locations

Optimal facility locations

Results 2-4: Chiradzulu district

Current situation– 12 health facilities– Average distance:

3.7km– One facility per

25000 people

Optimal locations– 5 existing facilities

remained open– 4 additional facilities

required– Total 9 facilities– Average distance:

3.5km– One facility per

32800 people

Challenges

Scarce resources in terms of skilled staff and equipment hence needs concentrated facilities. Not dispersed across small facilities

To provide care rather than cure. Care requires people rather than equipment, generalists rather than specialists. Access is more important

Access to Health a case for mobile clinics

• Mobile clinics have always been used.• There is need to reconsider• The manner in which they are deployed

will much depend on the local situation• May range from a simple boat to

sophisticated units.• These may be easier interventions and

much more basic.• Support to static units.

Access to Health a case for mobile clinics

• Currently – growth monitoring clinics ANC/U5C

• No organised treatment• Specialist monthly visits to the districts• Not predictable so not reliable• Consider specifically for personnel

Choosing a primary care package of health services

Important disease – burden of disease– Premature mortality– Major morbidity

Good intervention– Cheap– Acceptable– Practical– Possible

View from the Valley

• The effort to improve the HR problem will need to be intensified

• This should be both in numbers and quality• Senior health personnel will have to be at

the district. (Family Health Specialist)t• Access to health for the rural will have to

be improved. Static or mobile?• A big eye on HIV • Monitoring and Evaluation / Accountability

Implementation

Who?

How?

When?

Implementation - who

Implementation - how

We look further because we stand on the shoulders

of Giants

Dr David Livingstone

Thank you!