Clinton HIV/AIDS Initiative (CHAI)

Malawi Strategy Update

July 2009

CHAI operates in Malawi with a vision to strengthen health systems to enhance prevention, care, and treatment of HIV/AIDS in cooperation with the Ministry of Health and other partners. In doing so, we strive to ensure that our initiatives

  • Are agreed and implemented centrally with the MOH
  • Have the broadest possible beneficial impact for those in need
  • Focus district-level work initially by supporting PIH in Neno, implement PMTCT in the field in Machinga, and help improve overall health care in other districts as identified by MOH.

In pursuing this vision, we have adopted a “T-Shaped” approach to our strategy that drives our work (A) broadly/horizontally for national impact across the country and (B) deeply/vertically to demonstrate success and effectiveness in one or more areas that can then be leveraged to shape national policy and action plans.

Figure 1: “T-Shaped” Approach to Strategy

We utilize a professional, systematic approach to project management and monitoring and evaluation (M&E), holding ourselves accountable and accepting nothing less than achievement of programme goals through a well-defined and executed process and activities, demonstrating progress along the way, and producing measurable results.

This T-Shaped approach is exemplified in seven key areas of our existing work in Malawi. The Letter (A) or (B) next to each item corresponds to Figure 1:

  1. Policy advice, support, and technical assistance to the Ministry of Health. Achievements include changes in Malawi’s ART Guidelines that have allowed the introduction of FDCs for paediatric AIDS care of infants and clinical trial support for expansion of FDCs to children over 11KG in weight, and advocacy of universal ART for HIV+ infants <12 months of age. (A).
  2. Procurement and Distribution of ARV and Diagnostics for paediatric care (over 10,000 children on ART) as well as for Adult 2nd line therapy (A). The goal here is to lower the cost of treatment and facilitate drug availability through forecasting procurement and supply chain management.
  3. Paediatric Nutrition Programmefor HIV/AIDS. Support the MOH’s Out-Patient Therapy Programme (OTP) to treat children with Severe Acute Malnutrition (SAM) using Community-based Therapeutic Care (CTC). A key element of this is to link SAM care and treatment to HIV/AIDS testing, treatment, and follow-up. CHAI has had extensive involvement in scaling up CTC in Malawi, providing training for active case finding and Ready-To-Use Therapeutic Food (RUTF) for the OTP program in Mwanza, Neno, and Chitipa Districts (B). CHAI provides RUTF to 14 additional districts and is the dominant programmatic service provider and supplier in Malawi (over 16,000 children treated) and works with the MOH to drive the programme nationally. We believe this is the largest programme of its kind in the world. (A) and (B). CHAI also supports local sourcing from multiple suppliers to maximize distribution efficiencies and minimize cost.
  4. Laboratory Services Programme. In this Human Resources for Health (HRH) initiative, we support and enhance Lab Services by expanding critical human resources through training and development (Lab Assistants) and by selectively improving infrastructure, supplying equipment and reagents. In the Lab HRH programme, we revised the national training curriculum for lab assistants and are supporting the training over 80 new Lab Assistants nationally at the Malawi College of Health Sciences. These will almost double the number of technicians at rural health centres in Malawi. The programme is highly effective with significant field work and with two-thirds of the students in field labs at any point in time during the two-year training programme (A).
    Infrastructure: We are also providing support to build, refurbish, equip, supply and provide technical support and lab assistants for the District Lab and 10 Health Centre labs in Neno District and for the District Lab in Mwanza District. (B)
  5. PMTCT Programme. In this area, our goal is to support and drive PMTCT enhancement and scale-up. We have supported policy and programme development including participating in the rewriting of PMTCT Guidelines and helping initiate the national Early Infant Diagnosis (EID) programme. Success has included changes in national policy to support combination prophylaxis rollout in place of just sdNVP, early initiation of ART for infants, piloting EID in 15 sites in two regions, and supporting the subsequent rollout of EID to the Southern Region. (A) and (B). Malawi is also discussing extended infant prophylaxis as a result of the PEPI study.
    We have pending a proposal awaiting funding to help achieve Malawi’s vision of an HIV-free generation by supporting the comprehensive and effective implementation of all elements of the Malawi MOH PMTCT programme in the Machinga District (B). We will then take the learning from that, both throughout the programme and at its conclusion, to shape the national action plan (A). For this proposal, CHAI has developed a comprehensive set of eight strategic actions to achieve success in prevention of HIV infection via vertical transmission through two primary targets in the selected District:
  6. CHAI aims to dramatically increase the percentage of pregnant women accessing the full range of PMTCT services to at least 80% from the current 24.1% of pregnant women who were tested for HIV in 2007.
  7. CHAI aims to significantly decrease by at least 50% the rate of mother-to-child transmission from the current 30-45% level to 15-22.5% (target 15%), with a “stretch target” of achieving a 70% reduction to a range of 9-13%.
  8. Paediatric Programme to support paediatric HIV/AIDS outreach and services in Lilongwe and provide technical assistance with paediatric clinical trials. CHAI has achieved national policy changes in ART guidelines to treat HIV+ infants and has helped launch and is participating in the clinical trial for treatment of HIV+ children. CHAI also provides drugs for paediatric care in Malawi (See 2. above) (A). Recently, CHAI launched an initiative to expand the MOH’s ART programme M&E. (A)
  9. Following a lengthy review by MOH, NAC, and GOM ethics committee, CHAI has launched a “Disaggregated Outcomes Assessment Project” that is taking place from April-Aug 2008 using digital imaging, data entry, and analysis. This will result in improved measurement of outcomes of Malawi’s ART programme.
  10. For the first time since inception of Malawi’s ART effort, the MOH will know outcomes by age and gender as well as other critical information. They will also have a backup record of all data from every ART site in the country resulting in a significant improvement in data security and availability.

When funding sources become available, the paediatric programme also intends to launch a “deep-dive” initiative to address “Loss To Follow-Up” (LTFU) in one or more Districts, both to assess the causes of LTFU nationally and to develop a strategy and implementation plan to minimize this and bring patients in need of treatment back into care and treatment and increase retention of those already in care and treatment (A) and (B).

  1. Rural Delivery of Quality Integrated Health Care Services. In partnership with Partners In Health (PIH) in the Neno District, we are supporting their efforts with the district by supplying the full range of CHAI support: ARV procurement and distribution, Labs & Diagnostics, Early Infant Diagnosis (EID) Sample Transport, Nutrition and Community Health Worker training, as well as health care infrastructure and health worker housing. (B)

Figure 2: Project Management and M&E

Across all programmes, we are committed to active project management in which we define, measure, analyze, improve, and control processes, measure progress and monitor results in order to improve the programmes and deliver the desired results.

BUDGET:

Total Operating Budget of $7 million for FY 2009 across all programs, excluding overhead.

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