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News from around VSO > Malawi

Gap filling or life saving?

(September 22 2005)

VSO Chief Executive, Mark Goldring, talks about health, Malawi and VSO's new programme there.

A tough decision

It was a tough decision to start pulling out of supporting health care provision in one of the world's poorest countries, but pulling out is what VSO felt it had to do in Malawi in early 2004. Volunteers were working in such a dysfunctional situation that they could neither deliver effective care themselves nor contribute effectively to strengthening it for the future.

The trauma of having the skills to make a difference as to whether patients lived or died, but not even having the drugs or infrastructure to provide basic treatment made volunteers' roles impossible. And while we were involved in some sensible staff training programmes, few of those trained in professional roles stayed in the public health system longer than they had to.

We agreed to try one more time

However, after discussions and negotiations through 2004 with the Department for International Development (DfID) and the Ministry of Health we agreed to try one more time, crucially as part of a co-ordinated programme involving government, donors and ourselves.

Now, as I visit Dr Tjitske Dijkstra, a recently arrived Dutch VSO volunteer in a hospital two hours along a main road from Lilongwe, not a lot seems, at first glance at least, to have changed. There are two fully trained doctors, where before there was one. But they serve a catchment of about 400,000 people, and Tjitske’s colleague has also to administer the hospital and all the neighbouring health centres. To make matters worse, he has to do so without any real control over the resources theoretically under his management.

The district hospital of 300 beds acts as a point of referral for all the surrounding health centres. But it has a shortage of all medical cadres and, at the time of our visit, no penicillin or drugs to treat malaria or meningitis. Patients are dying of easily treatable conditions under the staff’s very eyes.

Humbled and horrified

I am humbled and horrified by what Tjitske has to cope with. She is often equally horrified and occasionally desperate. She takes some comfort from the fact that her colleagues have been coping with it for many years, and she is only experiencing what they do. Recognising this context offers some explanation for a seeming lack of professionalism in many colleagues and breeds admiration for a skill and dedication that defies explanation in others.

Nationally, over sixty percent of all nursing roles are vacant and the higher the level of professional the bigger the shortage. The most highly trained staff have the most opportunities for alternative work elsewhere, whether Botswana, the UK or the expanding NGO sector in Malawi itself. In spite of training over 20 doctors a year for many years, there are only about 120 Malawian doctors working in a country with a population bigger than greater London and nearly as large as the Netherlands. This total includes specialists, those in the private sector and the Minister of Health himself! Over a hundred new Malawian health workers a year register in the UK, and despite supposedly strict NHS rules on recruiting from African countries, adverts for jobs in the British private sector still regularly appear in the press.

Expectant mothers arrive at the hospital undernourished and often HIV positive. Many more don’t get as far as hospital. While there has been progress in many areas, including child health, maternal mortality in Malawi has risen over the last ten years and is now projected at about 1,800 per hundred thousand births. If each mother has five or six children she has a ten per cent chance of dying in childbirth.

Up to 50% of patients in the hospital are HIV positive and admitted with one symptom or other linked to HIV & AIDS. For most there is still no treatment. There are believed to be over a million children who have lost one or both parents.

The hospital facilities look poorly maintained. There is a tiny maintenance budget and everything looks overcrowded, tatty and makeshift. But when you look a little closer you see that most of the important things do now work - the water, the sanitation and the electric fire that serves instead of the broken incubator.

An hour down the road at a nurse training school two VSO nurse trainers, Lisa Worden and Stephen Free have recently arrived to teach nurses on the three year nursing/midwifery course. Their students start enthusiastic. It’s a challenge to keep them that way. Out of an intended staff complement of nine, there are five tutors in post including the two VSO nurse trainers. Four tutors left in 2003 to go to Botswana or the UK and could not be replaced and the staff on the wards where they practise are too stretched and de-motivated to offer them much support.

The school, and mission hospital to which it is attached, are well run, and, because they charge (very low) fees, better resourced than the government hospital at which Tjitske and John work. However, the combination of AIDS and the collapse of the government provision has led to a steady increase in new patients which they can’t cope with.

Costs have risen but people can’t afford higher charges; the charge of one dollar for all care associated with a Caesarean doesn’t cover anything like the full cost, but many patients can’t pay the low fees in place now. The hospital struggles to maintain its commitment to offer to treat all who need it, while earning enough money to stay open.

Nkhoma Hospital has no national doctors. (The Dutch doctor in charge recently finished three years as a VSO doctor in Namibia.) They are far from a town and there is no accommodation available for more doctors, nurses or tutors, nor any money to build more. The tarred road to the village that is being built will bring more patients long before it brings more staff.

Looking at the figures

It is easy to explain the state of the health service when you look at the figures. The World Health Organisation (WHO) calculates that per capita expenditure of about $34 a head is needed to deliver basic health care; 17 to deliver Malawi's most basic package. Malawi has been spending about $12, of which 4 dollars is by the patients themselves. Staff salaries are so low, and often so late, that it is easy to explain why Malawi has 29 nurses per hundred thousand of the population against South Africa's 472. Similarly, why no one wants, and few accept, a rural posting where there are few other earning opportunities and probably no school close by for their children. 1,700 of the 2,020 senior nursing posts are vacant.

Seeds of hope

Spending three days visiting such institutions brings powerful and mixed emotions. Horror, despair, guilt, overwhelming admiration for those who do work passionately within the system, anger at those who bleed it- and just a few seeds of hope. Enough seeds of hope indeed to be confident that, despite the grim picture, VSO was right to go back in, and do something both to help patients today and the availability of skilled staff tomorrow.

Miracles haven’t happened yet, but plans, commitments and the beginnings of action have. I’m pleased that we are part of it.

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