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TRAINING AND MENTORSHIP OF HEALTH

PROVIDERS:Malawi’s Approach

Aida Yemane BerhanTechnical Advisor, Malawi

Elizabeth Glaser Pediatric AIDS Foundation

June 17, 2010

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Malawi Background• Population: Approximately 13 million

• HIV prevalence: 12%

• 90,000 new HIV infections each year among adults

• Estimated 1 million people living with HIV(UNICEF 2008)

– 102,000 HIV-infected children below 15 years

– Over 1 million children orphaned due to AIDS

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Status of HIV/AIDS Services in Malawi • The PMTCT program has registered tremendous scale-up with

respect to number of sites that are offering the service– From 137 (28% ) of health facilities in 2006– Up to 544 (100%) in 2009

• Increased percentage of pregnant women tested & counseled for HIV– From 25% in 2006– Up to 67% in 2009

• Coverage of HIV testing and ARV prophylaxis has been difficult to track due to the absence of standardized monitoring tools until the end of 2009. With this limitation: – HIV positive pregnant women receiving complete course of ARV

prophylaxis:• From 50.5% in 2007 • Up to 81.7% in 2008

– Women receiving ARV PMTCT is reported to be 38.8% • Using population-based data from: Population Census, 2008 & MoH PMTCT Program Data, 2009

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Status of HIV/AIDS Services in Malawi

• Number of HIV-exposed infants receiving ARV prophylaxis rose from 5,558 in 2006 to 20,058 in 2008

• Major strides in PMTCT also include the EID program in over 41 sites

• Rapid acceleration of the ART program. Tremendous progress has been registered:– With only 10,761 people on ART in 2004, the figures have risen to

198,846 in 2009 (Adults: 181,482; Children: 17,364)

• ART sites have increased from 9 in 2003 to 377 (279 static clinics and 98 outreach/mobile clinics) as of December 2009

• Between July 2008 and June 2009, 1,079,598 first-time testers accessed HTC services and these constituted 63% of all the clients tested in the period

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EGPAF Malawi’s Program Progress • In 2002 in collaboration with local partners , initiated one of

Malawi’s first programs to provide PMTCT

• In 2005, received funding through the USAID Call to Action project to support PMTCT activities

• In 2006 , the foundation was supporting 54% of all PMTCT services available

• Established an office in 2008 with the request of MOH to: – Support MOH at national level in building capacity to manage the

PMTCT program , development of guideline, revision of policy, improvement of M & E system including zonal mentorship program

– Continue supporting implementing partner (LMRFT) which is currently providing TA to 41 sites in Lilongwe districts

– Expand TA to more districts in central west zone , Dedza and Ntcheu districts to 51 sites

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PMTCT Program in MalawiThe program now focuses its efforts on:

– Improving access to comprehensive PMTCT services:• Scale-up of TA from 4 sites in 2003 to 91 sites in 2010

– Building facility and staff capacity for PMTCT service provision• Carry out assessment, TOT and training of service providers,

mentorship and supportive supervision

– Increase efficacy of PMTCT programs nationwide• EGPAF collaborates with MOH and other partners on zonal mentorship

program , training of coordinators for safe motherhood, PMTCT, and RH to perform regular supervision and performance review

– Reducing HIV-related stigma and increasing community involvement • EGPAF partners with organization to create supportive environment for

mothers which includes support groups for HIV-positive lactating mothers, and counseling and testing of male partners

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EGPAF Malawi’s Program Progress

• More than 3,000 health care providers trained on PMTCT, adherence support, pediatric HIV care

• Increased uptake of PMTCT at 41 EGPAF-supported sites in 2009 – 99% of women attending ANC receive counseling and

testing– 95% HIV+ women receive ARVs– 60% of infants receive ARVs– Expand technical support to an additional 51 sites in 2010

• Carried out a PMTCT capacity assessment in Dedza and Ntcheu districts where EGPAF is expanding TA for PMTCT services

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Rationale for Zonal Mentorship Program

While the rapid scale up of PMTCT sites was a commendable success, quality of service delivery was a concern to MOH and partners including:

• Inadequate staff coordinating the PMTCT program at national level

•Relatively inadequate partners, funding for PMTCT program in the country

•Relatively poor M&E system– Frequently changing data recording tools (e.g. 3 times in 2009 alone)– Staff not oriented on the use of the tools– Lack of standardized PMTCT supervision tool– Inadequate supervision of PMTCT sites by district PMTCT coordinators

• Lack of coordination among the coordinators of HIV, ART, PMTCT, RH, FP, safe motherhood, laboratory and pharmacies at both national and district level

• Frequent stock out of PMTCT supplies

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Malawi’s Zonal Mentorship Program

• EGPAF formed a partnership with the MOH, MSH/BASICS, UNICEF and other HIV partner organizations to embark on a Zonal Mentorship Program for PMTCT nationwide

• The program goals are:

1. To improve the quality of program implementation through joint and regular review of programs performance

2. To build the capacity of the District Coordinators on PMTCT supervision

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Malawi’s Zonal Mentorship Program

• Carried out 3 rounds of zonal mentorship training in 2009

• The zonal mentorship training workshops are preceded by national PMTCT site supportive supervision visits

• 3-4 teams comprising MOH PMTCT coordinators, district PMTCT coordinators and PMTCT partners are involved in supportive supervision

• From each district 3-4 PMTCT sites (90-120 sites at a time) are mentored and supervised with the focus on:– Availability & capacity of human resources; integration of PMTCT into

MCH; Linkage of PMTCT to ART; expansion of combination ARV prophylaxis provision; mother-baby pair follow-up; EID; supplies; BCC; IYCF; data recording & reporting

• Each supervision team provide feed back to the facilities and the districts, discuss on challenges & solutions

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Zonal Mentorship Program Achievements

• District PMTCT coordinators have improved their capacity to mentor and supervise PMTCT service providers

• There is good initiative in coordination of activities among PMTCT, safe motherhood and family planning coordinators in the integrated management of PMTCT

• The coordination will extend more to the other HIV programs, such as ART, HTC & STI

• Increased motivation of service providers

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Zonal Mentorship Program Achievements

• PMTCT-related voices from remote health centers are now easily heard at the national level

• Improvement of M&E

• Expansion of sites providing combination ARV prophylaxis

• Updates on PMTCT, pediatric HIV, and other related issues were effectively disseminated to the facilities

• DHOs have recognized the need to improve quality of PMTCT services and have started to invest more in PMTCT

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Lessons Learned

• Strong MOH/NAC leadership and program ownership are vital for effective program implementation and sustainability

• Coordination of programs, services, and partners is the key for efficiency and effectiveness of program implementation

• Mentorship and supportive supervision motivates staff and they take the initiative to perform better and be creative

• Building the capacity of the Districts Coordinators and Zonal Supervisors in PMTCT would contribute to the improvement of access and quality of the service significantly

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Challenges

• Inadequate funds to support the zonal mentorship program

• Lack of adequate staff in MOH to coordinate PMTCT at national level

• Relatively few PMTCT partners in the country

• Poor infrastructure in health facilities

• Poor logistics and resources in the districts to maintain the program

• Poor community linkage of the program

• More resources and efforts required to ensure coordination among the coordinators of ART, HTC, FP, safe motherhood, RH, nutrition

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Newly renovated health center in central west zone in Malawi

DISCLAIMER: This program was made possible through support provided by the Office of HIV/AIDS, Global Bureau Center for Population, Health and Nutrition, of the United States Agency for International Development (USAID), through the President’s Emergency Plan for AIDS Relief, as part of the Elizabeth Glaser Pediatric AIDS Foundation's International Family AIDS Initiatives (“Call To Action Project”/ Cooperative Agreement No. GPH-A-00-02-00011-00). Private donors also supported costs of activities in many countries. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.

ZICOMU QUAMBIRI

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