100,000 people started on ART with very limited human resources. - Experiences from Malawi 14 June 2007 Dr Kelita Kamoto Dr Erik Schouten HIV/AIDS Unit

100,000 people started on ART with very limited human

resources.-

Experiences from Malawi 14 June 2007

Dr Kelita KamotoDr Erik SchoutenHIV/AIDS UnitMinistry of HealthMalawi

HIV & AIDS Unit MOH Malawi

Human Resources crisis Principles of ART programme Task shifting Outcomes of ART programme Some issues around ART scale up


Malawi 12 million inhabitants

GDP US$ 200

930,000 people infected (14% of adult population)

90,000 HIV/AIDS deaths annually

Severe HRH crisis

Main health care providers: Ministry of Health and Christian Health Association of

Malawi (CHAM) Small private for profit health sector International NGOs and research institutions involved in

ART


Vacancies in MOH and CHAM

Posts EHP Posts filled % vacancies

Medical Doctors 433 162 63%

Clinical Officers 1,405 1,033 26%

Nurses 8,440 3,416 60%

Medical Assistants 1500 491 67%

Pharmacy technician 269 134 50%

Med Lab technician 507 182 64%

Health Surv. Assist. 11,000 4,664 58%

June 2006


Human Resources GoM declared a crisis of human resources; the

health sector ‘has collapsed’ (Secretary for Health)

Chakrabarti / Piot (February 2004); the health sector human capacity crisis in Malawi is an emergency ‘requiring exceptional measures that might otherwise be dismissed as unsustainable’HIV is an advocate for Health systems strengthening

This lead to 6-year Human Resources Emergency Relief Plan (US$ 273 million)


Principles of ART Programme

Based on realities (a public health approach): Simple (1st Line regimen only, one regimen for all, no

laboratory monitoring or CD4 count needed, drug supply, short training, intensive quarterly supervision)

Standardised (case finding, treatment regimen, reporting and monitoring). All providers following national protocol.

Inclusive (all providers involved: mission hospitals, profit and not-for profit private sector)

Lower cadres of staff involved (task shifting)


Task shifting in Malawi Clinical officers and medical assistants for a long

time work as medical doctors. Have specialised in orthopaedic, anaesthesia, psychiatry, dermatology, ophthalmology, etc

Nurses run health centres as clinicians apart from normal nursing duties

HSAs are microscopists for malaria and TB sputum apart from preventive activities, vaccination and health promotion

HSAs involved in HIV testing and counselling Non medical health workers involved in HTC,

nutrition clinics, Community Home Based care and follow up patients (incl. adherence)


ART health care provider model Medical officers, clinical officers, nurses and medical

assistants can prescribe ART Decision to allow nurses to initiate treatment made

in June 2007. (Support through Act of parliament, NMCM)

In day-to-day practice some tasks are carried out by e.g. clerks (follow up on ART)

Research into identification of patients and follow up of ART in stable patients by HSAs

Community workers targeting PLWHA to follow up ART to stable patients


ART health care provider model (2) All health workers in ART clinics have been

trained (one week intensive training, followed by 2 week attachment in well established clinic), passed an exam, certified and registered with the Medical Council

The national ART guidelines describe the scope of practice

Intensive quarterly supervision of all ART sites


National laws or policies that facilitates task shifting Policies and laws exists allowing nurses to prescribe. Regulatory bodies made a positive decision on nurses to initiate

ART. We are waiting for approval of volunteers and HSAs to follow up (including re-supply) ART to patients?

The laws are silent on ART moving to health centres. In general health centres do not provide complicated interventions (ART seen as such).

The law is silent on volunteers handling drugs such as anti-malarials and pain-killers

The government at all levels including regulatory bodies have accepted task shifting with the aim of: Increasing access to health services To utilise available human resource at nearest

community/facility


Outcomes ART programme 140 sites (government, mission, private sector)

100,000 people ever started (over 70,000 alive and on treatment)

2006 - 2010 Scale up plans to start treatment for 45,000 people per year (50% of people becoming eligible for ART)

Number of people alive on treatment

% of adult population on treatment

2006 60,000 1%

2010 160,000 2.5%

2015 210,000 3.5%


Number of sites providing HAART

0

20

40

60

80

100

120

140

160

Jun-02 Dec-02

Jun-03 Dec-03

Jun-04 Dec-04

Jun-05 Dec-05

Jun-06 Dec-06

Private sector

Public sector


Number of people ever started on HAART

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

Jun-02

Dec-02

Jun-03

Dec-03

Jun-04

Dec-04

Jun-05

Dec-05

Jun-06

Dec-06

Date

Ever started

Alive and ontreatment


Equity. Who has access to ART?

Research to socio-economic, geographic and demographic determinants of access.

Example:Proportion of HIV infected population accessing ART by 31st December 2006

6 districts had a relative low uptake of ART services:DedzaMangochiPhalombeNtcheuMulanjeMachinga


Do ART services take away staff from other essential health services?In June 2006:

with 43,390 people alive and on ART (59,851 people ever started)

916 health worker days per week required to run the ART clinics

257 HCW lives saved is equivalent to 1,139 extra staff days in the health sector

(presentation on the study in the Implementers Meeting

and will be published in Bulleting of WHO)


Mortality in 8 private sector companies and Malawi Defence Forces MBCA ART sites. 7/10 provided data Most companies provide data on employees

and spouses, one on employees, spouses and other dependents

No point in time of start of ART (often senior management first, followed by other staff

Number of staff “stable”


Mortality in 8 Private sector companies

2002 2003 2004 2005 2006

Overall

Dwangwa Matiki HC

Water board

Unilever

Shire Buslines

ADMARC

SOBO/Carlsberg

Portland

ESCOM

Mortality (adjusted) in 8 Companies in Malawi


2002 2003 2004 2005 2006

Mortality in MDF from 2002 -2006

soldiers

Dep

Total


Costs of the ART programme

By 2015 costs of ART only will be US$ 40 – 50 million per year. This would increase the health budget by approximately 30%

Number of people alive and on ART

-

50,000

100,000

150,000

200,000

250,000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

year

nu

mb

er High estimate

Low estimate

Costs of Malawi ART programme

-

10

20

30

40

50

60

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

US

$ (

mil

lio

n)

high estimate

low estimate


Costs of the ART programme

Average costs of ART per person per year

Costs of ARVs pppy (see next slide) US$ 148.09

CTX for CPT 10.37

Drugs for HIV related diseases 10.00

Therapeutic feeding 21.35

Costs for training, IEC, M&E, supervision, OR, health education, infrastructure, etc.

24.35

Staff costs per person per year on ART 4.80

Other service delivery costs (running costs clinic, laboratory support)

10.00

Average costs US$ 228.96


Average costs of ARVs per person per year

Monthly Costs of ARVs (FOB)

Costs per year (US$) inclusive of all costs

Proportion of people on each regimen

1st line regime (d4T,3TC,NVP) 7.76

130.08 95.0%

alt 1st line regime I (ZDV,3TC,NVP) 16.43

275.53 3.0%

alt 1st line regime II (d4T,3TC,EFV) 26.50

444.41 1.0%

2nd line regime (ZDV,3TC,Tenofovir,Lopinavir/Ritonavir) 70.35 1,179.77 1.0%

Average costs for ARVs per person per year 148.09


Achievements

ART programme based on ‘public health principles’ works (4th highest coverage of ART in SSA).

Task shifting is accepted by government and was at the basis of the scale up of ART.

Quarterly supervisory and monitoring visits with feedback on quality of services provided (certificate of excellence or letter to improve the service) providing good data on ART scale up.

Government and regulatory bodies commitment in enhancing ART programmes.


Challenges

Demand for training in ART is in excess of supply. ART curriculum in pre-service in the teaching

institution does not lead to certification (duplication of training).

HSAs is an unregulated cadre. Step to allow non-health workers providing ART

services is difficult and can only be made after positive results of research.

Financial sustainability of the programme. Equity and access.


Thank you

Documents

100,000 people started on ART with very limited human resources. - Experiences from Malawi 14 June 2007 Dr Kelita Kamoto Dr Erik Schouten HIV/AIDS Unit