Dear Sir/Madam, POSITION PAPER ON HUMAN RESOURCES FOR HEALTH IN MALAWI- INTRODUCTION OF FEES FOR STUDENT NURSES/MIDWIVES AND OTHER HEALTH CARE WORKERS BACKGROUND · Role of nurses, midwives and other healthcare workers o Nurses, midwives and other healthcare workers have a mission to improve delivery of quality health services in the country. By empowering nurses and midwives professionally and socio-economically, the nation is assured of improved health services to the people of Malawi. Adequate numbers of nursing/midwifery personnel is essential in the delivery of the Essential Health Package. o However, Human Resources for Health crisis is a challenge to the provision of adequate and quality health services in order to meet socio-economic targets set in the MDGs and MGDS. Currently, there are approximately 4,450 nurses/midwives practising in the public sector, and a prevailing 76% vacancy rate in the country. · Introduction of fees for training nurses and midwives o Human Resources for Health crisis can comprehensively be addressed in a three-pronged Treat, Train, and Retain Strategy. However, recent developments on the introduction of fees for nurses/midwives training pose a threat towards addressing the Human Resources for Health crisis. On 17th September 2009, the Ministry of Health indicated that it would not be in a position to financially support next intakes in CHAM colleges citing critical budgetary constraints and the ending of a six-year Emergency Human Resource Development Programme. o On the same date, CHAM communicated to College Principals to implement a decision that continuing students should contribute K35,000 per year towards their studies; while new intakes (1st years) should pay fees amounting K335,000 per year. The situation is similar at Malawi College of Health Sciences. AIM OF POSITION PAPER · As voices of the poor parents; and patients as consumers of healthcare; as well as healthcare workers who bear the burden of shortage; we Civil Society Organisations and Trade Unions ask for revision of government decision on payment of fees by students and parents towards training in nursing and midwifery. · Specifically, the fees are very high costing over K1 million per student for a 3-years course of study. This is prohibitive to selected candidates who aspire to study nursing/midwifery. Therefore, we feel that successful lessons from history and other sectors can be used to address the issue. Existing and alternative funding options can be maximised to address funding for nurses and midwives training. As Civil Society, we recognise our critical role in complementing government efforts to develop the country socio-economically taking it from ‘Poverty to Prosperity’. We, therefore take keen interest in the health of the people of Malawi in order to preserve the ‘Economic Miracle’ gained over the past 6 years. We believe that together, we can discover a meaningful and sustainable way forward towards funding the training of nurses and midwives. EFFORTS TO ADDRESS HUMAN RESOURCES FOR HEALTH SITUATION · We, recognise that the Ministry of Health complemented by development partners has put in place programmes in pursuit of its objective to increase the availability of qualified staff in health facilities; · Emergency Human Resource Programme has been instrumental since 2004 focusing on infrastructure expansion and sstrengthening pre-service training in health training institutions; rehabilitation of infrastructure; and improving incentives to ensure delivery of Essential Health Package; · Budgetary trends in the national budget (8% in 2006/07 to 13.24% in 2009/10) and allocations towards human resource development in the health sector have been increasing over the past 5 years (5.8% in 2007/08 to 5.24% in 2009/10). CHALLENGES FACING HUMAN RESOURCES FOR HEALTH · We are cognisant of the challenges facing the health sector regarding Human Resources for Health. The sector faces a critical shortage of health workers; high disease burden mainly due to preventable diseases and conditions such as malnutrition, sanitation and lack of universal access to safe water. Other challenges include capacity constraints in training institutions due to lack of adequate teaching space, hostels and shortage of tutors; and reliance on external funding; and effects of global economic meltdown. SITUATION ANALYSIS · Historical Background The situation on the ground looks gloomy and retrogressive. Nursing/midwifery has evolved with training funding provided by government and complemented by missionaries and donors, since pre-colonial era through colonial to independence until the current democratic era. As when history repeats itself, only 3 students have been enrolled at St Joseph College of Nursing against the over selected 60 students. The similar scenario occurred in 1951 when there were 3 students in class at Zomba General Hospital upon introduction of formal nurse training in the country. · Affordability Majority of Malawians are poor who can not afford to pay K335,000 fees per year. As a result, less than 200 out of the selected 600 students have reported for classes in the 9 CHAM colleges. Even those who have reported for classes have only paid instalments “waiting for a miracle to happen”. The detailed situation is as follows: o Nkhoma College of Nursing selected 50 candidates none of which has reported for classes; o St Johns College of Nursing selected 60 candidates out of which only 28 have reported for classes; o Malawi College of Health Sciences selected 110 students for nursing/midwifery, none of which has reported for classes; o Mulanje Mission College of Nursing selected 65 students of which 57 have reported for classes and only 4 have indicated ability to pay. o Trinity College of Nursing selected 49 candidates of which only 9 have indicated ability to pay. o Malamulo College of Health Sciences selected 135 candidates (including Clinical Officers) of which only 30 have reported for classes. · Impact on the healthcare system and existing workforce o Gains achieved over the years will not be consolidated eventually affecting the pace of achievement of the health-related Millennium Development Goals (MDGs); o Infrastructure expansion project (2004-2009) funded by Norwegian Church Aid in the 9 CHAM colleges will be put to waste if few students register for studies. The investment comprised building student hostels; classrooms; library; steel laboratory equipment and tutors houses with additional capacity building of tutors and provision of learning materials; o With the prevailing vacancy rate (76%) amongst nurses; and overall 18,000 vacancies amongst all healthcare workers, the desired nurse: population ratio of 1:1700 by 2011 will not be achieved. o The crisis has impact on health Indicators such as: maternal health that requires skilled attendants at birth. o Adequate numbers of healthcare workers serve patients better hence meeting the demands of consumers of healthcare according to the Patients Rights Charter. o The increased fees is a recipe for migration to greener pastures because graduates will opt to work abroad for a quick payback for the training cost. o Payment of fees by student and their parents can be likened to liberalisation and privatisation of the healthcare system which is unaffordable to the majority poor Malawians. BEST PRACTICES WHICH CAN BE ASSIMILATED TO THE HEALTH SECTOR Best practices from other sectors can be assimilated to the financing issue for nurses/midwives training: · Government subsidy on farm inputs; · Government funding for training of careers and professionals in uniform; · Parastatal subventions by government; · Tax holidays awarded to investors i.e. on buses; · Over-collection of revenue by Malawi Revenue Authority some of which can be used to train healthcare workers. OUR POSITION · We, the Civil Society Organisations, on behalf of patients and communities as consumers of health services; the majority poor families; nurses and midwives & students; other healthcare workers; state our demands on new fees; o Projections based on training all students in nursing and other health training institutions per year would cost at least K2billion per year which we strongly feel government can afford. · We therefore, call upon our leaders in Government; Development Partners; International Financing Institutions; Members of Parliament and other Political leaders; CHAM: Proprietors and institutions; Community and Religious leaders; Patients and Consumer groups; and the Private Sector, to: · Identify measures and financial resources for training nurses/midwives and other healthcare workers. · Maximise the country’s capacity to increase domestic revenue through taxes and other means whose proceeds should be used build the human capital essential for socio-economic development; · Identify additional external resources to address the issue; · Identify alternative options such as: introduction of Public loans and Scholarships just like University of Malawi and Mzuzu University; · Forward Planning should be effected to identify alternatives in the event of winding up of programmes such as the Emergency Human Resource Programme; · The decision to charge fees for student nurses and midwives training will impact negatively on Patients/Clients and Communities. The majority poor have the public health services as the only alternative source of care. · Prioritise the training of nurses/midwives to achieve socio-economic development targets in the Millennium Development Goals (MDGs) and the Malawi Growth and Development Strategy (MDGS);