Health Care Workers In Malawi Research Articles

The mental health toll among healthcare workers during the COVID-19 Pandemic in Malawi

The COVID-19 pandemic has affected the mental health of healthcare workers worldwide, with frontline personnel experiencing heightened rates of depression, anxiety, and posttraumatic stress. This mixed-methods study aimed to assess the mental health toll of COVID-19 on healthcare workers in Malawi. A cross-sectional survey utilising the Generalized Anxiety Disorder (GAD-7), Patient Health Questionnaire (PHQ-9), and Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) was conducted among 109 frontline healthcare workers. Additionally, in-depth interviews were conducted with 16 healthcare workers to explore their experiences and challenges during the pandemic. The results indicated a high prevalence of COVID-19-related depression (31%; CI [23, 41]), anxiety (30%; CI [22, 40]), and PTSD (25%; CI [17, 34]) among participants. Regression analysis revealed significantly higher rates of depression, anxiety, and PTSD among healthcare workers in city referral hospitals compared to district hospitals. Qualitative findings highlighted the emotional distress, impact on work and personal life, and experiences of stigma and discrimination faced by healthcare workers. The stress process model provided a valuable framework for understanding the relationship among pandemic-related stressors, coping resources, and mental health outcomes. The findings underscore the urgent need for interventions and support systems to mitigate the mental health impact of COVID-19 on frontline healthcare workers in Malawi. Policymakers should prioritise the assessment and treatment of mental health problems among this critical workforce to maintain an effective pandemic response and build resilience for future crises.

Health care providers acceptance of default prescribing of TB preventive treatment for people living with HIV in Malawi: a qualitative study

BackgroundTuberculosis (TB) preventive treatment (TPT) substantially reduces the risk of developing active TB for people living with HIV (PLHIV). We utilized a novel implementation strategy based on choice architecture (CAT) which makes TPT prescribing the default option. Through CAT, health care workers (HCWs) need to “opt-out” when choosing not to prescribe TPT to PLHIV. We assessed the prospective, concurrent, and retrospective acceptability of TPT prescribing among HCWs in Malawi who worked in clinics participating in a cluster randomized trial of the CAT intervention.Methods28 in-depth semi-structured interviews were conducted with HCWs from control (standard prescribing approach) and intervention (CAT approach) clinics. The CAT approach was facilitated in intervention clinics using a default prescribing module built into the point-of-care HIV Electronic Medical Record (EMR) system. An interview guide for the qualitative CAT assessment was developed based on the theoretical framework of acceptability and on the normalization process theory. Thematic analysis was used to code the data, using NVivo 12 software.ResultsWe identified eight themes belonging to the three chronological constructs of acceptability. HCWs expressed no tension for changing the standard approach to TPT prescribing (prospective acceptability); however, those exposed to CAT described several advantages, including that it served as a reminder to prescribe TPT and routinized TPT prescribing (concurrent acceptability). Some felt that CAT may reduce HCW´s autonomy and might lead to inappropriate TPT prescribing (retrospective acceptability).ConclusionsThe default prescribing module for TPT has now been incorporated into the point-of-care EMR system nationally in Malawi. This seems to fit the acceptability of the HCWs. Moving forward, it is important to train HCWs on how the EMR can be leveraged to determine who is eligible for TPT and who is not, while acknowledging the autonomy of HCWs.

Factors Influencing the Implementation of Infant Warming Devices Among Healthcare Workers in Malawian Hospitals.

Objectives. Preterm infants are at risk of hypothermia. This study described the available infant warming devices (IWDs) and explored the barriers and facilitators to their implementation in neonates in Malawi. Methods. A qualitative descriptive study was conducted among 19 health care workers in Malawi from January to March 2020. All interviews were digitally recorded, transcribed, and managed using NVivo and analyzed using a thematic approach. Results. The warming devices included radiant warmers, Blantyre hot-cots, wall-mounted heaters, portable warmers, and incubators. Inadequate equipment and infrastructure and gaps in staff knowledge and capacity were reported as the main challenges to optimal IWD implementation. Caregiver acceptance was described as the main facilitator. Strategies to optimize implementation of IWD included continuous practical training and adequate availability of equipment and spare parts. Conclusion. Implementation of warming devices for the management of neonatal hypothermia is effective when there are adequate human and material resources.

A Heart for the Care: Affect, Kin, and Care Work in a Zambian Hospital.

At the only standalone pediatric hospital in Zambia, patient wellbeing often rests in the hands of bedsiders. Bedsiders are caregivers, often family, who sit at the patient's bedside, feeding, cleaning them, and running medical errands. Bedsiders are critical human infrastructure for the hospital and its staff. In our research, we heard repeatedly that bedsiders must have a "heart" for caregiving, taking on unremunerated and exhausting informal labor. We draw on Wendland's "heart for the work," a phrase commonly used among healthcare workers in Malawi and Zambia describing the medical profession, to explore what this metaphor reveals about care.

Uptake of the COVID-19 vaccine among healthcare workers in Malawi.

Little is known about coronavirus disease 2019 (COVID-19) vaccination in Africa. We sought to understand Malawian healthcare workers' (HCWs') COVID-19 vaccination and its hypothesized determinants. In March 2021, as the COVID-19 vaccine roll-out commenced in Malawi, we surveyed clinical and lay cadre HCWs (n=400) about their uptake of the vaccine and potential correlates (informed by the WHO Behavioral and Social Drivers of COVID-19 Vaccination framework). We analyzed uptake and used adjusted multivariable logistic regression models to explore how 'what people think and feel' constructs were associated with HCWs' motivation to be vaccinated. Of the surveyed HCWs, 82.5% had received the first COVID-19 vaccine dose. Motivation (eagerness to be vaccinated) was strongly associated with confidence in vaccine benefits (adjusted OR [aOR] 9.85, 95% CI 5.50 to 17.61) and with vaccine safety (aOR 4.60, 95% CI 2.92 to 7.23), but not with perceived COVID-19 infection risk (aOR 1.38, 95% CI 0.88 to 2.16). Of all the information sources about COVID-19 vaccination, 37.5% were reportedly negative in tone. HCWs in Malawi have a high motivation to be vaccinated and a high COVID-19 vaccine uptake. Disseminating vaccine benefits and safety messages via social media and social networks may be persuasive for individuals who are unmotivated to be vaccinated and less likely to accept the COVID-19 vaccine.

A qualitative study of barriers and facilitators to adequate environmental health conditions and infection control for healthcare workers in Malawi

Abstract The burden of healthcare-associated infections (HAIs) is high in low- and middle-income countries. Inadequate environmental health (EH) conditions and work systems contribute to HAIs in countries like Malawi. We collected qualitative data from 48 semi-structured interviews with healthcare workers (HCWs) from 45 healthcare facilities (HCFs) across Malawi and conducted a thematic analysis. The facilitators of infection prevention and control (IPC) practices in HCFs included disinfection practices, patient education, and waste management procedures. HCWs reported barriers such as lack of IPC training, bottlenecks in maintenance and repair, hand hygiene infrastructure, water provision, and personal protective equipment. This is one of the most comprehensive assessments to date of IPC practices and environmental conditions in Malawian HCFs in relation to HCWs. A comprehensive understanding of barriers and facilitators to IPC practices will help decision-makers craft better interventions and policies to support HCWs to protect themselves and their patients.

Working lives of maternity healthcare workers in Malawi: an ethnography to identify ways to improve care

BACKGROUNDMaternal mortality in East Africa is high with a maternal mortality rate of 428 per 100,000 live births. Malawi, whilst comparing favourably to East Africa as a whole, continues to have a high maternal mortality rate (349 per 100,000 live births) despite it being reduced by 53% since 2000. To make further improvements in maternal healthcare, initiatives must be carefully targeted and evaluated to achieve maximum influence. The Malawian Government is committed to improving maternal health; however, to achieve this goal, the quality of care must be high. Furthermore, such a goal requires enough staff with appropriate training. There are not enough midwives in Malawi; therefore, focusing on staff working lives has the potential to improve care and retain staff within the system.OBJECTIVEThis study aimed to identify ways in which working lives of maternity healthcare workers could be enhanced to improve clinical care.STUDY DESIGNWe conducted a 1-year ethnographic study of 3 district-level hospitals in Malawi. Data were collected through observations and discussions with staff and analyzed iteratively. The ethnography focused on the interrelationships among staff as these relationships seemed most important to working lives. The field jottings were transcribed into electronic documents and analyzed using NVivo. The findings were discussed and developed with the research team, participants, and other researchers and healthcare workers in Malawi. To understand the data, we developed a conceptual model, “the social order of the hospital,” using Bourdieu's work on political sociology. The social order was composed of the social structure of the hospital (hierarchy), rules of the hospital (how staff in different staff groups behaved), and precedent (following the example of those before them).RESULTSWe used the social order to consider the different core areas that emerged from the data: processes, clinical care, relationships, and context. The Malawian system is underresourced with staff unable to provide high-quality care because of the lack of infrastructure and equipment. However, some processes hinder them on national and local level, for example staff rotations and poorly managed processes for labeling drugs. The staff are aware of the clinical care they should provide; however, they sometimes do not provide such care because they are working with the predefined system and they do not want to disrupt it. Within all of this, there are hierarchical relationships and a desire to move to the next level of the system to ensure a better life with more benefits and less direct clinical work. These elements interact to keep care at its most basic as disruption to the “usual” way of doing things is challenging and creates more work.CONCLUSIONTo improve the working lives of the Malawian maternity staff, it is necessary to focus on improving the working culture, relationships, and environment. This may help the next generation of Malawian maternity staff to be happier at work and to better provide respectful, comprehensive, high-quality care to women.

Perceptions of expressed breast milk for preterm infants in Malawian hospitals: A qualitative study

BackgroundExpressed breastmilk (EBM) can support lactation for mothers of preterm infants with underdeveloped feeding skills. However, there may be implementation challenges in resource-limited global health settings. ObjectiveTo explore EBM barriers and facilitators perceived by caregivers and healthcare workers in Malawi. MethodsA secondary analysis of in-depth interviews exploring breastfeeding support at health facilities conducted at three secondary-level district hospitals and one tertiary-level central hospital in southern Malawi. Interviews underwent content analysis in NVivo 12 (QSR International, Melbourne, Australia). ResultsThere were 58 healthcare workers and 54 caregivers interviewed. Caregiver unfamiliarity, maternal exhaustion, and inadequate clinical support/equipment were barriers to EBM practice. Caregiver acceptance was supported by witnessing infant growth. Demonstrations of EBM by healthcare workers and family support also facilitated practice. ConclusionRaising community awareness and extending counselling to family members upon initiation are vital to supporting mothers practice EBM in resource-limited global health settings with chronic staffing shortages.

Comparative evaluation of a low-cost solar powered otoscope with a traditional device among health care workers in Malawi.

ObjectivesTo comparatively evaluate a low‐cost otoscope with a traditional device among health care workers in Malawi.MethodsThe study is a prospective, comparative, qualitative observational survey of health care worker's opinions using 5‐point Likert rating scales and tick box categories in a 10‐item survey questionnaire. Twenty‐five mixed cadre health care workers from the Ear, Nose, and Throat Department of the Queen Elizabeth Hospital, Blantyre in Malawi were recruited. Outcomes measures used were ease of speculum attachment, handling, insertion, stability, the quality of view, color, build, brightness, overall ease of use, and their suitability for local work.ResultsThe low‐cost otoscope scored statistically higher in overall combined performance, as well as in the remaining four out of the nine attributes. Notably, 54.2% of users rated the low‐cost device more suitable than the traditional device for use in low‐middle income countries, 25% were equivocal, and 20.8% preferred the traditional device.ConclusionThis study found the Arclight otoscope to be an appropriate and practical substitute for more expensive traditional otoscopes for the delivery of ENT services in low resource settings.Level of EvidenceN/A

Comparative evaluation of a low cost direct ophthalmoscope (Arclight) for red reflex assessment among healthcare workers in Malawi

We compared the diagnostic performance and ease of use of a new solar powered low-cost Arclight direct ophthalmoscope (AO) to a more expensive traditional direct ophthalmoscope (TDO) (Keeler Professional V.2.8)...

"I do all I can but I still fail them": Health system barriers to providing Option B+ to pregnant and lactating women in Malawi.

Malawi’s Option B+ program is based on a ‘test and treat’ strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits.

Learning from the experience of maternity healthcare workers in Malawi: a qualitative study leading to ten low-cost recommendations to improve working lives and quality of care

BackgroundIn Malawi there are too few maternity healthcare workers to enable delivery of high quality care to women. These staff are often overworked and have low job satisfaction. Skilled maternity healthcare workers are essential to improve outcomes for mothers and babies. This study focuses on understanding the working life experience of maternity staff at district hospitals in Malawi with the aim of developing relevant low-cost solutions to improve working life.MethodsA qualitative study using semi-structured interviews was undertaken in three district hospitals around Malawi’s Capital city. Thirty-one staff formed a convenience sample, purposively selected to cover each cadre. Interviews were recorded, transcribed and then analysed using Interpretative Phenomenological Analysis complemented by Template Analysis to elicit the experience of maternity staff.ResultsStaff describe a system where respect, praise and support is lacking. Many want to develop their skills, however, there are barriers to advancement. Despite this, staff are motivated; they are passionate, committed professionals who endeavor to treat patients well, despite having few resources. Their ‘superdiverse’ background and experience helps them build resilience and strive to provide ‘total care’.ConclusionsImproving working lives can improve the care women receive. However, this requires appropriate health policy and investment of resources. There are some inter-relational aspects that can be improved with little cost, which form the ten recommendations of this paper. These improvements in working life center around individual staff (respecting each other, appreciating each other, being available when needed, performing systematic clinical assessments and communicating clearly), leadership (supportive supervision and leading by example) and the system (transparent training selection, training being need driven, clinical skills being considered in rotation of staff). To improve working lives in this way will require commitment to change throughout the health system. Thus, it could help address preventable maternal and newborn deaths.

Burnout and self-reported suboptimal patient care amongst health care workers providing HIV care in Malawi.

BackgroundThe well-documented shortages of health care workers (HCWs) in sub-Saharan Africa are further intensified by the increased human resource needs of expanding HIV treatment programs. Burnout is a syndrome of emotional exhaustion (EE), depersonalization (DP), and a sense of low personal accomplishment (PA). HCWs’ burnout can negatively impact the delivery of health services. Our main objective was to examine the prevalence of burnout amongst HCWs in Malawi and explore its relationship to self-reported suboptimal patient care.MethodsA cross-sectional study among HCWs providing HIV care in 89 facilities, across eight districts in Malawi was conducted. Burnout was measured using the Maslach Burnout Inventory defined as scores in the mid-high range on the EE or DP subscales. Nine questions adapted for this study assessed self-reported suboptimal patient care. Surveys were administered anonymously and included socio-demographic and work-related questions. Validated questionnaires assessed depression and at-risk alcohol use. Chi-square test or two-sample t-test was used to explore associations between variables and self-reported suboptimal patient care. Bivariate analyses identified candidate variables (p < 0.2). Final regression models included variables with significant main effects.ResultsOf 520 HCWs, 62% met criteria for burnout. In the three dimensions of burnout, 55% reported moderate-high EE, 31% moderate-high DP, and 46% low-moderate PA. The majority (89%) reported engaging in suboptimal patient care/attitudes including making mistakes in treatment not due to lack of knowledge/experience (52%), shouting at patients (45%), and not performing diagnostic tests due to a desire to finish quickly (35%). In multivariate analysis, only burnout remained associated with self-reported suboptimal patient care (OR 3.22, [CI 2.11 to 4.90]; p<0.0001).ConclusionBurnout was common among HCWs providing HIV care and was associated with self-reported suboptimal patient care practices/attitudes. Research is needed to understand factors that contribute to and protect against burnout and that inform the development of strategies to reduce burnout.

Comparative evaluation of a novel solar powered low-cost ophthalmoscope (Arclight) by eye healthcare workers in Malawi

This study compared a novel low-cost solar powered direct ophthalmoscope called the Arclight with a traditional direct ophthalmoscope (TDO). After appropriate training, 25 Malawian eye healthcare workers were asked to...

Echoes of old HIV paradigms: reassessing the problem of engaging men in HIV testing and treatment through women\u2019s perspectives

BackgroundWith the introduction of 2016 World Health Organization guidelines recommending universal antiretroviral therapy (ART), there has been increased recognition of the lack of men engaging in HIV testing and treatment. Studies in sub-Saharan Africa indicate there have been challenges engaging men in HIV testing and HIV-positive men into treatment.MethodsThis qualitative study explored women’s perspective of their male partner’s attitudes towards HIV and ART and how it shapes woman’s experience with ART. Data were collected through in-depth interviews and focus group discussions with HIV-positive pregnant and postpartum women on Option B+ and health care workers in Malawi and Zimbabwe. In Malawi, 19 in-depth interviews and 12 focus group discussions were conducted from September–December 2013. In Zimbabwe, 15 in-depth interviews and 21 focus-group discussions were conducted from July 2014–March 2014.ResultsThe findings highlighted that many men discourage their partners from initiating or adhering to ART. One of the main findings indicated that despite the many advancements in HIV care and ART regimens, there are still many lingering negative beliefs about HIV and ART from the earlier days of the epidemic. In addition to existing theories explaining men’s resistance to/absence in HIV testing and treatment as a threat to their masculinity or because of female-focused health facilities, this paper argues that men’s aversion to HIV may be a result of old beliefs about HIV and ART which have not been addressed.ConclusionsDue to lack of accurate and up to date information about HIV and ART, many men discourage their female partners from initiating and adhering to ART. The effect of lingering and outdated beliefs about HIV and ART needs to be addressed through strengthened communication about developments in HIV care and treatment. Universal ART offers a unique opportunity to curb the epidemic, but successful implementation of these new guidelines is dependent on ART initiation and adherence by both women and men. Strengthening men’s understanding about HIV and ART will greatly enhance women’s ability to initiate and adhere to ART and improve men’s health.

Knowledge and attitudes toward HIV, hepatitis B virus, and hepatitis C virus infection among health-care workers in Malawi

Objective:The highest prevalence of HIV infection occurs in Sub-Saharan Africa and hepatitis B virus (HBV), and hepatitis C virus (HCV) prevalence are the second highest in Sub-Saharan Africa including Malawi. Health-care workers (HCWs) play an important role in the prevention of, response to, and management of these infectious diseases. There is, however, no published research about the level of knowledge and attitudes toward HIV, HBV, and HCV infection among Malawian HCWs. The purpose of this study was to explore and determine the knowledge of and attitudes toward HIV, HBV, and HCV among a targeted population of Malawian HCWs.Methods:A cross-sectional community-based participatory research with 194 HCWs was completed employing health survey method. The project was a collaborative effort between nursing faculties in the USA and Malawian. A one-way analysis of variance (ANOVA) with the Bonferroni adjustment for multiple comparisons was used to assess the differences in knowledge and attitude among three subgroups of HCWs.Results:Of 194 of Malawian HCWs surveyed, 41% were support staff, 37% were nursing students, and 22% were health-care professionals. Both health-care professionals and support staff had high knowledge scores related to HIV/AIDS, and their attitudes were mainly positive. However, a series of one-way ANOVAs revealed significant differences in knowledge and attitude toward HIV/AIDs, HBV, and HCV among HCWs (P < 0.01). The majority had less knowledge about HBV and HCV and more negative attitudes toward hepatitis.Conclusions:This study highlights the ongoing need for reducing negative attitudes toward HIV, HBV, and HCV; and providing health education among HCWs, especially focusing on HBV and HCV prevention. The findings of the research project can be used to develop interventions addressing low HBV- and HCV-related knowledge and attitudes.

Deficiencies in education and experience in the management of acute kidney injury among Malawian healthcare workers.

Acute kidney injury (AKI) is a common but under-recognised disease process, which carries a high risk of mortality or chronic complications, such as chronic kidney disease and other organ dysfunction. Management of AKI, however, is suboptimal, both in developed settings and in Malawi. This is partly because of deficiencies in AKI education and training. To establish current levels of AKI education in a range of healthcare workers in Malawi. An AKI symposium was held in Blantyre in March 2015. Delegates were asked to complete a survey at the start of the symposium to assess their clinical experience and education in the management of AKI. From 100 delegates, 89 nurses, clinical officers, and physicians, originating from 11 different districts, responded to the survey. Twenty-two percent of healthcare workers (including 28% of district workers of the various cadres and 31% of nurses) had never received teaching on any aspect of renal disease, and 50% (including 63% of district workers and 61% of nurses) had never received teaching specifically on AKI. Forty-four percent did not feel confident managing AKI, and 98% wanted more support managing patients with renal disease. Thirty-four percent (including 55% of district workers) were unaware that haemodialysis was available at Queen Elizabeth Central Hospital (QECH) for the treatment of AKI and 53% (74% of district workers) were unaware that peritoneal dialysis was available for the treatment of AKI in children. Only 33% had ever referred a patient with AKI to QECH. There are deficiencies in education about, and clinical experience in, the management of AKI among Malawian healthcare workers, in addition to limited awareness of the renal service available at QECH. Urgent action is required to address these issues in order to prevent morbidity and mortality from AKI in Malawi.

Supporting middle-cadre health care workers in Malawi: lessons learned during implementation of the PALM PLUS package.

BackgroundThe government of Malawi is committed to the broad rollout of antiretroviral treatment in Malawi in the public health sector; however one of the primary challenges has been the shortage of trained health care workers. The Practical Approach to Lung Health Plus HIV/AIDS in Malawi (PALM PLUS) package is an innovative guideline and training intervention that supports primary care middle-cadre health care workers to provide front-line integrated primary care. The purpose of this paper is to describe the lessons learned in implementing the PALM PLUS package.MethodsA clinical tool, based on algorithm- and symptom-based guidelines was adapted to the Malawian context. An accompanying training program based on educational outreach principles was developed and a cascade training approach was used for implementation of the PALM PLUS package in 30 health centres, targeting clinical officers, medical assistants, and nurses. Lessons learned were identified during program implementation through engagement with collaborating partners and program participants and review of program evaluation findings.ResultsKey lessons learned for successful program implementation of the PALM PLUS package include the importance of building networks for peer-based support, ensuring adequate training capacity, making linkages with continuing professional development accreditation and providing modest in-service training budgets. The main limiting factors to implementation were turnover of staff and desire for financial training allowances.ConclusionsThe PALM PLUS approach is a potential model for supporting mid-level health care workers to provide front-line integrated primary care in low and middle income countries, and may be useful for future task-shifting initiatives.

Evaluating a streamlined clinical tool and educational outreach intervention for health care workers in Malawi: the PALM PLUS case study

BackgroundNearly 3 million people in resource-poor countries receive antiretrovirals for the treatment of HIV/AIDS, yet millions more require treatment. Key barriers to treatment scale up are shortages of trained health care workers, and challenges integrating HIV/AIDS care with primary care.The researchPALM PLUS (Practical Approach to Lung Health and HIV/AIDS in Malawi) is an intervention designed to simplify and integrate existing Malawian national guidelines into a single, simple, user-friendly guideline for mid-level health care workers. Training utilizes a peer-to-peer educational outreach approach. Research is being undertaken to evaluate this intervention to generate evidence that will guide future decision-making for consideration of roll out in Malawi. The research consists of a cluster randomized trial in 30 public health centres in Zomba District that measures the effect of the intervention on staff satisfaction and retention, quality of patient care, and costs through quantitative, qualitative and health economics methods.Results and outcomesIn the first phase of qualitative inquiry respondents from intervention sites demonstrated in-depth knowledge of PALM PLUS compared to those from control sites. Participants in intervention sites felt that the PALM PLUS tool empowered them to provide better health services to patients. Interim staff retention data shows that there were, on average, 3 to 4 staff departing from the control and intervention sites per month. Additional qualitative, quantitative and economic analyses are planned.The partnershipDignitas International and the Knowledge Translation Unit at the University of Cape Town Lung Institute have led the adaptation and development of the PALM PLUS intervention, using experience gained through the implementation of the South African precursor, PALSA PLUS. The Malawian partners, REACH Trust and the Research Unit at the Ministry of Health, have led the qualitative and economic evaluations. Dignitas and Ministry of Health have facilitated interaction with implementers and policy-makers.Challenges and successesThis initiative is an example of South-South knowledge translation between South Africa and Malawi, mediated by a Canadian academic-NGO hybrid. Our success in developing and rolling out PALM PLUS in Malawi suggests that it is possible to adapt and implement this intervention for use in other resource-limited settings.

A national survey of the impact of rapid scale-up of antiretroviral therapy on health-care workers in Malawi: effects on human resources and survival.

To assess the human resources impact of Malawis rapidly growing antiretroviral therapy (ART) programme and balance this against the survival benefit of health-care workers who have accessed ART themselves. We conducted a national cross-sectional survey of the human resource allocation in all public-sector health facilities providing ART in mid-2006. We also undertook a survival analysis of health-care workers who had accessed ART in public and private facilities by 30 June 2006, using data from the national ART monitoring and evaluation system. By 30 June 2006, 59 581 patients had accessed ART from 95 public and 28 private facilities. The public sites provided ART services on 2.4 days per week on average, requiring 7% of the clinician workforce, 3% of the nursing workforce and 24% of the ward clerk workforce available at the facilities. We identified 1024 health-care workers in the national ART-patient cohort (2% of all ART patients). The probabilities for survival on ART at 6 months, 12 months and 18 months were 85%, 81% and 78%, respectively. An estimated 250 health-care workers lives were saved 12 months after ART initiation. Their combined work-time of more than 1000 staff-days per week was equivalent to the human resources required to provide ART at the national level. A large number of ART patients in Malawi are managed by a small proportion of the health-care workforce. Many health-care workers have accessed ART with good treatment outcomes. Currently, staffing required for ART balances against health-care workers lives saved through treatment, although this may change in the future.