Our Projects

Health Sector Reform and Development

The achievement of the Millennium Development Goals (MDGs) by 2015 will only be possible if we can successfully strengthen the capacity of health systems in middle and low-income countries.

The WHO’s Commission on Macroeconomics and Health identified human resource issues as major constraints in meeting targets to scale up interventions and meet the MDGs. Primary Health Care (PHC) services have been greatly affected by the shortage of human resources. In some countries the combination of large numbers of HIV patients and the serious weakening of health systems from the loss of skilled workers to HIV/AIDS, means that vulnerable groups are denied access to even basic PHC. The depletion of human resources is particularly acute at the district and community levels, as there are fewer incentives and support structures available to attract and retain staff.

Malawi is one of the poorest nations in the world, with some of the worst health worker to population ratios. Most health services are provided by clinical officers, medical assistants and enrolled nurses. The government has taken action to address the staffing shortfall, estimated at 15,000.

In 2001 a Six-Year Emergency Training Plan for health workers was supported by Malawi’s major donors. Further programs included a health initiative launched in 2004 to deliver an Essential Health Package, including an Emergency Human Resources Program. This aimed to improve staff recruitment and retention through salary top-ups and increased training. It also included international technical assistance to support planning and management capacity, and short-term use of international volunteer doctors and nurse tutors.

In 2005 the government introduced a 52 percent salary top-up which, combined with further increases, resulted in professional health workers being the highest paid civil servants. However, although there have been some increases in staff numbers, there is as yet little published evidence regarding the impact of these salary increases.

Research in Malawi’s health facilities has shown that factors other than pay, such as training and career advancement, are critical in retaining and motivating existing staff. Resource shortages in clinics negatively affect staff motivation and inadequate management support leads to job dissatisfaction.

Progress on the training and career development aspects of the Emergency Human Resources plan has been slow. The 2007-2011 Human Resources Strategic Plan set out to address the complex problem of motivating and retaining staff, particularly in rural areas, and other issues highlighted by research. The new Human Resources Development Policy (2007) focuses on training and the importance of performance monitoring to maximize human resource capacity.

Ensuring that these strategies and policies result in improved health outcomes will depend on:

  • Regular and rigorous monitoring of indicators and targets
  • Sufficient HR management capacity at local level to implement the HR development policy
  • Equal emphasis on motivating and retaining existing staff versus recruiting additional staff
  • A long-term strategy to ensure adequate funding for health worker salaries

HSI developed a comprehensive human resource plan covering all positions within the Malawi Health Service. The plan included innovative strategies for retention, training, and recruitment of health service staff. The plan was adopted by the Government and formed the basis for successful mobilization of over $200 million in donor funding. See NAM for a description of the long term benefits of this program.

The program will increase the UK’s spending in Malawi by 50 per cent and will result in a 30 per cent rise in Malawi’s total health budget.

In January 2006, the Malawi Health Minister Hetherwick Ntaba stated, "the number of resignation letters from nurses has reduced from six per month to almost none." He said the reduction could partly be attributed to health sector reform implemented with funding from the Department for International Development (DfID) and Global Fund. Ntaba said since government started to provide remuneration supplement to health workers in April, the morale among nurses has improved.

"Before the remuneration supplement in April, we were having more than 120 nurses going to the UK," he said. "Although they are working in harsh conditions, we have seen the improvements in their morale." He said with the US$100 million from DfID and another US$100 million from Global Fund, government was optimistic that it would alleviate problems in the health sector.