Nurse/Midwife Training Operational Plan Field Assessments, Analysis and Scale- up Plans for Nurse Training Institutions

Transcription

1 GOVERNMENT OF MALAWI MINISTRY OF HEALTH Nurse/Midwife Training Operational Plan Field Assessments, Analysis and Scale- up Plans for Nurse Training Institutions September 2

2 Table of Contents Acronyms... 3 Foreword... 4 Acknowledgements... 5 Executive Summary... 6 Introduction... 7 Training Institution Scale- up Objectives... 7 Background... 8 Nursing Education Landscape... 9 Roles of Ministries, Regulatory Bodies and Other Agencies in Nursing Education... Significant Past Nursing Interventions... 2 Hiring and Deployment... 2 Methodology... 4 Objective... 4 TI Assessment Questionnaire... 4 Piloting Student Questionnaire... 4 Expert Interviews... 4 Comprehensive Feedback Meeting with Proprietors and Principals... 5 Stakeholder Meetings... 5 High- level Findings... 6 Analysis... 8 Targets... 8 Recommended Standards... 9 Classroom/Clinical Facility Optimization... 2 Determining Teaching Requirements... 2 Non- Residential Students by Region Type... 2 Looking Forward: Increasing TI Capacity... 2 System- level Recommendations Prioritization by Cost- Effectiveness Overall Resource Needs Next Steps Appendix : TI Questionnaire Appendix 2: Staggered Intake Example

3 Acronyms CHAM DFID EHRP GAIA GTZ HCW HRH HRHTWG KCN M&E MCHS MoE MoH MSF NCA NMT NMCM PEPFAR POW RN SWAp TI WHO Christian Health Association of Malawi Department for International Development, UK Emergency Human Resource Plan Global AIDS Interfaith Alliance Deutsche Gesellschaft für Technische Zusammenarbeit Healthcare Worker Human Resources for Health Human Resources for Health Technical Working Group Kamuzu College of Nursing Monitoring & Evaluation Malawi College of Health Sciences Ministry of Education Ministry of Health Médecins Sans Frontières Norwegian Church Aid Nurse Midwife Technician Nurses and Midwives Council of Malawi U.S. President s Emergency Plan for AIDS Relief Program of Work Registered Nurse Health Sector- wide Approach Training Institution World Health Organization 3

4 Foreword The Ministry of Health has produced this operational plan to enable it to address serious nurse/midwife shortages in public and private sector hospitals in Malawi. This document sets out work plans for training institutions to follow in order to increase their training capacity, and in turn the output of these critical health workers, in a responsible and cost- effective manner. Government institutions and development partners can then use this plan to direct investments in training institutions. This will result in significant reductions in the Ministry s staffing vacancies in nurse/midwives over the next five years. The Nurse/Midwife National Training Operational Plan is aligned with Malawi s Health Sector Strategic Plan and has received the full endorsement of the Ministry s senior management as well as its technical arms, the HRH Technical Working Group, training institutions and stakeholders as an official plan to increase training capacity. I encourage all stakeholders to commit to the implementation of this operational plan over the next five years as part of the Ministry s endeavor to provide quality health care for all in Malawi. Hon. Dr. Jean A.N. Kalilani, M.P. Minister of Health 4

5 Acknowledgements The Ministry of Health acknowledges the active participation of the Nurses and Midwives Council of Malawi (NMCM); Christian Health Association of Malawi (CHAM); Kamuzu College of Nursing (KCN); Malawi College of Health Sciences (MCHS); Mzuzu University; Ministry of Education and the principals and proprietors at all nursing/midwifery training institutions in Malawi. Special thanks go to staff in the Ministry of Health involved in this project. The Ministry of Health thanks the Clinton Health Access Initiative (CHAI), who provided the financial and technical assistance for the development of the operational plan. I thank them for their efforts and contribution in the collection and analysis of data. Despite the likely obstacles and challenges in implementation of the operational plan I am confident in its implementation through your usual commitment and cooperation. Dr. Charles Mwansambo Principal Secretary Ministry of Health 5

6 Executive Summary The following operational plan contains the output from a comprehensive assessment of nursing/midwifery TIs in Malawi carried out by the Ministry of Health (MoH) in collaboration with CHAI between July and September 2. The assessments were conducted to determine the resources required to scale up the capacity of the training institutions to eliminate the existing nursing and midwifery vacancies at health facilities across Malawi. Using data from these assessments, a thorough analysis was conducted to create tailored 5- year operational plans to support the government and CHAM TI s strategic and financial planning. The assessment consisted of field visits and individual analysis of 6 nurse/midwifery TIs and expert interviews with leaders in professional health care associations, the MoH, regulatory bodies and donors, as well as partner and stakeholder meetings. The field visits enabled surveyors to understand both opportunities and challenges in scaling up training capacity without sacrificing training quality. Further, surveyors worked with the Nurses and Midwives Council of Malawi (NMCM) and MoH staff to determine appropriate standards around faculty ratios, classroom size, student accommodation and learning resource requirements. This ensured quality standards were maintained in establishing scale- up activities for each TI. Strategies such as a staggered intake for enrollment and introducing a shift to non- residential students in urban areas were explored in an effort to make the most of existing resources. Additionally, faculty ratios, academic calendars, and NMCM approved curricula were all carefully developed in collaboration with experts to determine recruitment needs for new faculty. The following recommendations were developed to scale- up training capacity by maximizing government and partner funding. Based on initial estimates, an investment of USD 27,5, and approximately 265 additional teaching staff is recommended to scale- up all nursing/midwifery TIs, increasing the annual student intake from the current,39 to 2,278 by 26. This would result in 2,78 net new nurse/midwives trained by 28, completely eliminating the current staffing gap by 29 (and a population- growth adjusted staffing gap by 224). Recruitment and retention of dedicated teaching staff was identified as one of the major challenges to increasing training capacity and improving education quality. TIs located in rural areas have a particularly difficult time attracting faculty, most of whom prefer to reside in urban locations where accommodation and amenities are more readily available. Staffing and logistics relating to clinical instruction were also commonly cited, as ensuring students were deployed to appropriate practical sites remains a considerable challenge. The great majority of TIs noted that there were a large number of qualified student candidates who were not admitted due to a lack of capacity at the school, thereby establishing that there is a large pool of qualified applicants available to support an increase in future intakes at the TIs. To support funding prioritization, TIs have been ranked based on the total cost per- student to double first- year intake at each school. This way, finite government and partner resources can be directed in a cost- effective way to the TIs to support efforts to reach staffing targets in the health sector. 6

7 Introduction Malawi is suffering from a severe HRH shortage. It is estimated that Malawi is currently operating at 33% of the healthcare workers (HCWs) necessary to effectively deliver healthcare services to the population. Through an examination of the pipeline of nurse/midwives in Malawi, it was established that the driving factor in the shortage of staff is the limited number of existing training slots for these cadres. Therefore, the Nurse/Midwife Training Operational Plan was conducted to establish specific guidelines to scale up the number of highly skilled and qualified nurse/midwives serving in MoH and CHAM health facilities in Malawi. MoH employs the majority of pre- service and in- service students immediately after graduation and thus has a direct stake in training of health students. However, TIs either operate as private proprietorships under CHAM or are statutory organizations that report to the Ministry of Education (MoE). It is therefore important that any scale- up activities to address the nursing and midwifery shortage are determined in conjunction with CHAM and MoE. While scale- up recommendations and activities should be managed by MoH, critical input and sign- off with MoE, CHAM and regulatory bodies are also required to effectively direct external funding to TIs. Training Institution Scale- up Objectives In July and August 2, MoH conducted field visits to all the nurse/midwifery TIs in Malawi to determine the resources needed and the readiness of the TIs to expand in order to help achieve the target staffing levels for nurses/midwives. The visits enabled MoH to develop actionable operational plans for each TI with estimated costs for items required to increase the number of enrolled students in order to help meet existing MoH staffing targets. The process enabled the MoH to: Compare the MoH determined staffing establishment against the current maximum student intakes/graduates set by the TIs to understand the current supply and shortage of nurse/midwives; Identify innovative and cost- effective opportunities, as well as resource needs by TIs to scale- up training capacity; Identify opportunities for improved training quality (i.e. improved student to teacher ratios, improved access to clinical instruction); and Determine a target date by which MoH would meet staffing establishment targets for nurse/midwives. MOH HRMIS, September 2 2 MOH HRMIS and CHAM HR Vacancies List, September 2 7

8 Background Overall Nursing/Midwifery Shortage As a result of the significant shortage of nurse/midwives coupled with their critical role in the country s health system, nurse/midwives report feeling overworked and being placed in harsh work environments. Dozens of health facilities lack a full- time nurse/midwife, particularly those in rural areas. Where full- time nurse/midwives are employed, their patient load is particularly substantial making it difficult for them to provide quality services to patients. Staff shortages among priority nurse/midwife cadres in MoH and CHAM are represented below 2 based on the staffing establishment approved in MOH HRMIS and CHAM HR Vacancies List, September 2 8

9 Nursing/Midwifery Education Landscape The following are the primary sub- cadres of nurse/midwives within Malawi s healthcare system and are thus the cadres of focus in this training operational plan: o o o o Nursing Officers: play a managerial and decision- making role at health facilities and are primarily located at district and central hospitals. These are the highest grade of nurse/midwives and are Registered Nurses with a Bachelors of Science Degree in Nursing and Midwifery obtained either from KCN or Mzuzu University. Nursing Officers play a critical role in providing sophisticated nursing services to patients however are infrequently found at health centers and hospitals in rural areas Nurse Midwife Technicians: are primarily found at health centers and community hospitals where Nursing Officers are generally limited in numbers, and play a significant role in general patient care as well as non- complicated deliveries given their substantial midwifery training. NMTs are trained through 3- year diploma programs at the majority of nurse/midwifery TIs in Malawi Community Health Nurses: although few are trained they provide critical nursing services to the hardest to reach rural communities. Community Health Nurses are trained through a one- year upgrading program at MCHS Psychiatric Nurses: primarily serve patients with mental illnesses at the two mental hospitals in Malawi, Zomba Mental Hospital and St. John of God Hospital. There are two categories of Psychiatric Nurses, degree- level Registered Psychiatric Nurses (trained at St. John of God College of Nursing) and diploma- level Psychiatric Nurse Technicians (trained at MCHS). 9

10 Nurse and Midwife Training Progression in Malawi 3 years Nurse Midwifery Technician (NMT) 2 2 years Registered Nurse Midwife (UDN) 2 2 years Professional Registered Nurse Midwife (UBSCN) 2 2 year Psychiatry Nurse Technician (PNT) year Community Health Nurse Technician (CHNT) 2 3 years Registered Nurse (DN) 4 years Professional Registered Nurse (BSCN) 2 2 years Registered Psychiatry Nurse (RPN) year Registered Midwife (UCM) years Masters in Nursing (PBN) o Key Certificate Diploma Degree Masters Doctorate Entry Point Path for DN Path for BSCN Minimum years of work experience required 4 years Doctorate in Nursing (PhD) Malawi s nursing/midwifery education landscape consists of a number of TIs of varying sizes, expertise and programs. TIs either operate privately under CHAM or are statutory organizations reporting to the MoE. However, given that graduating students from nursing/midwifery TIs are absorbed immediately into CHAM or MoH health facilities through a bonding agreement with students (with the exception of KCN and Mzuzu University), and since all HCWs within these organizations are paid through MOH, the department plays a significant role in training HCWs. The majority of CHAM TIs are smaller that Government TIs and are located in rural areas and almost exclusively train Nurse Midwife Technicians (NMTs), the largest nursing cadre in Malawi. Government TIs are larger, located in urban areas and primarily train Registered Nurses (RNs). Government TIs include: Kamuzu College of Nursing; (training degree- level RNs and is considered the flagship nursing college in Malawi) the Malawi College of Health Sciences; (individually the largest institution training mid- level nurse/midwives) and Mzuzu University s Health Sciences Department that also trains degree- level RNs. The following tables list the variety of training programs offered by Malawi nursing and midwifery TIs to help meet the critical human resource needs within Malawi: Government TIs: TI Name Programs Offered (Type, Length of Program) Kamuzu College of Nursing (KCN) Bachelors of Science in Nursing (Pre- service, 4 years) Bachelors of Science in Nursing (Post- Basic, 2 years) Diploma in Nursing (In- service, 2 years) Registered Midwife (In- service, year), Masters Degree in Nursing (2 years) 2 MCHS Blantyre Diploma in Nursing (Pre- service, 3 years)

11 3 MCHS Lilongwe Community Health Nursing (In- service, year) 4 MCHS Zomba Nurse Midwife Technician (Pre- service, 3 years), Psychiatric Nurse Technician (In- service, year) 5 Mzuzu University Bachelors of Science in Nursing and Midwifery (Pre- service, 4 years) Note: A fast track, modular nurse tutor training program (- year) and preceptor training program (4-6 weeks) are also under development at KCN. CHAM TIs: TI Name Programs Offered (Type, Length of Program) 6 Dae Yang Luke Diploma in Nursing (Pre- service, 3 years) 7 Ekwendeni Nurse Midwife Technician (Pre- service, 3 years) 8 Holy Family Nurse Midwife Technician (Pre- service, 3 years) 9 Malamulo Nurse Midwife Technician (Pre- service, 3 years) Mulanje Mission Nurse Midwife Technician (Pre- service, 3 years) Nkhoma Nurse Midwife Technician (Pre- service, 3 years) 2 St. John of God Registered Psychiatric Nurse (In- service, 2 years) 3 St. John s Nurse Midwife Technician (Pre- service, 3 years) 4 St. Joseph s Nurse Midwife Technician (Pre- service, 3 years) 5 St. Luke s Nurse Midwife Technician (Pre- service, 3 years) 6 Trinity Nurse Midwife Technician (Pre- service, 3 years) Roles of Ministries, Regulatory Bodies and Other Agencies in Nursing Education A number of organizations play a critical role in the training of nurse/midwives and their subsequent employment in Malawi public health system, the primary organizations are: a) MoH: Graduates from health TIs working in MoH or CHAM health facilities (including the majority of nurse tutors employed at TIs) are under MoH employment contracts; essentially TIs train for the public health system, which is managed by MoH. Nurse tutors, trained at KCN, are seconded by MoH to work at CHAM facilities for 2- years after graduation. These tutors can either renew their secondment agreement; enter an employment contract with the CHAM proprietor; move to another training institution; or work as a practicing nurse/midwife at a health facility. All these activities are facilitated by MoH. b) MoE: Government TIs are established as statutory corporations and report (both operationally and financially) to the MoE. As such, the MoE plays a critical role in decisions determining the scale- up of TIs. c) Nurses and Midwives Council of Malawi (NMCM): Nurse/midwife training curricula, prescribed training quality standards for TIs and ethical, conduct and professionalism standards for practicing nurse/midwives are established by NMCM. NMCM works with TIs to ensure training quality

12 standards are being met through monitoring and evaluation (M&E) activities; establishes training curricula; and conducts licensure and registration exams for nurse/midwives subsequent to graduation from TIs. While it is a body within the Government of Malawi, NMCM operates independently of MoH. Significant Past Nursing Interventions There are a number of previous HRH interventions that impacted nurse and midwifery training in particular that can offer insights to any future scale up of nursing training in Malawi: o o o o Infrastructure Scale- up and Capacity Building of TIs: Under the Emergency Human Resource Plan (EHRP) conducted from 24-2, CHAM and Government TIs received infrastructure upgrades including new hostels, classrooms, libraries, skills labs, dining halls and learning resources. CHAM TIs received their infrastructure support from Norwegian Church Aid (NCA) while Government TIs benefited from Health Sector Wide Approach (SWAp) funds from pooled donors. This led to substantial increases in nursing student enrollment and has improved overall training quality Salary Top- up and Locum Scheme: As part of the EHRP, priority HCWs, including nurse/midwives, received a taxed 52% salary top- up. The locum scheme enables nurse/midwives to pick up essential overtime shifts on off- days to further improve compensation. While the efficacy of the locum scheme has been uncertain, the 52% salary top- up is widely believed to have been effective in reducing attrition of nurse/midwives. Some nurse tutors have been able to participate in this 52% salary top- up Syllabus Changes to Nursing Programs: NMCM has undertaken significant revisions of existing nursing program syllabi to streamline and improve nurse/midwife training in critical areas. Generally, increased emphasis has been placed on clinical instruction and reducing syllabus congestion Additional Incentives for Tutors: Attrition of teaching staff has been a particular challenge in training qualified nurse/midwives. Many nurse tutors are seconded to CHAM TIs, which tend to be located in hard- to- reach rural areas, requiring nurse tutors to separate from their families, struggle to find basic amenities and quality schooling for their children as well as find additional income generating activities. GTZ has thus far supported additional top- up incentives for nurse tutors Primarily, HRH interventions as they relate to nurse/midwives have taken place under the first Program of Work (POW), which encompassed the EHRP. HRH decisions are fielded through the HRH Technical Working Group (HRHTWG), a decision- making mechanism led by the Ministry of Health that meets bi- monthly to develop evidence- based and strategic recommendations to inform, contribute and influence political and policy discussion as they relate to HRH issues. Hiring and Deployment The hiring and deployment process of recently graduated nurse/midwives is fairly rapid, in large part due to bonding arrangements for pre- service nursing students at CHAM TIs and in- service students at 2

13 both Government and CHAM TIs. MoH conducts career fairs at Government TIs to recruit pre- service students not under a bonding agreement. The Government of Malawi subsidizes student fees and in return students are expected to work in MoH or CHAM facilities after graduation for a minimum of five years. A Memorandum of Understanding between MoH and CHAM places 6% of new graduates at MoH health facilities and 4% at CHAM facilities. Students are required to sign a bonding agreement at the beginning of their nursing/midwifery education and are then deployed to districts upon graduation as student employees almost immediately after graduation. These student employees become fully- fledged employees once they pass their license exam administered by NMCM several months after graduation. MoH centralizes decisions around deployment of new graduates to particular districts. A new graduate will then report to their assigned District Health Office where the District Health Officer or District Nursing Officer will deploy them to a particular health facility. There is a 65% shortage of nurse/midwives in Malawi with many health facilities lacking a full time nurse/midwife. MoH s hiring budget is constrained by the funded establishment (set by the Department of Public Service Management), which represents the number of HCWs the Government of Malawi can employ. Currently, the funded establishment for nurse/midwives is significantly higher than the total number of filled posts and thus MoH would have Treasury authority to fill all vacant posts immediately. However, mobilizing and directing all these resources immediately would be difficult and therefore the scale- up timelines ensured that the public system could effectively absorb these new HCWs. 3

14 Methodology Objective In order to effectively carry out TI assessments, Excel- based questionnaires and analytical models were created to provide a standardized approach to collating data in order to establish the baseline capacity of TIs, discuss scale- up with TIs, report findings and analyze needs. All Government and CHAM TIs that train nurse/midwives were evaluated through this process. In total 6 TIs were included in this assessment. TI Assessment Questionnaire The visits to the TIs were structured around the information required by the Excel- based questionnaire and enabled the field team to capture key data such as: programs offered; historical student enrollment; current staffing; infrastructure; and transportation. The field visits were conducted with: the principal of the TI; two or more teaching staff, the bursar and the school registrar (where available). The questionnaire also incorporated a qualitative section covering issues such as faculty qualifications and development, teaching methods and student evaluation as well as a student questionnaire. Piloting Student Questionnaire After developing the TI assessment questionnaire, the field team performed a pilot field visit to assess the questionnaire s completeness and relevancy. KCN and Nkhoma College of Nursing were assessed in the pilot phase due to the different cadres trained, their government/cham contexts and varying size and complexity. The questionnaire was subsequently revised to reflect the priorities of the TIs. Some inputs were deemed irrelevant and were removed, while others areas were added and refined. Expert Interviews Interviews and meetings were conducted to identify opportunities and challenges relating to scale- up of TIs, understand existing assessments performed and help guide the assessments process. The interviews and meetings helped to inform the development of the assessment questionnaire, obtain relevant costing data, quality standards and viability of scale- up activities. The participants involved in interviews included the following: CHAM KCN, Principal MoH, Human Resource Department MoH, Planning Department MoH, Nursing Department National Organization of Nurses and Midwives Nurses and Midwives Council of Malawi NCA 4

15 Comprehensive Feedback Meeting with Proprietors and Principals In February 2, proprietors of TIs and their respective principals, deans and campus directors were invited to a meeting to share the initial findings and draft operational plans to solicit their feedback and input. Their input was highly appreciated and played a critical role in vetting the operational plans for key scale- up activities that may not have been captured in the analysis. Aside from the presence of all TIs, the following additional stakeholders were in attendance: Ministry of Health Planning Department Ministry of Health Human Resources section Ministry of Education Higher Education Department CHAM NCA NMCM NONM GIZ ITECH Breakout working sessions were conducted with meeting participants to review the draft operational plan and provide focused feedback on the following areas: Identification of general omissions or redundancies from the TOPs; Identification of potential cost- saving opportunities and review the viability of recommended cost saving activities made in the plan; Sufficiency of scale- up standards and costing; and Alignment of the operational training plan with TI strategic plans. Feedback provided by meeting participants was compiled and reviewed with MOH Nursing Department to vet the feedback as to whether it fit the scope of the NTOP and how to best integrate the relevant feedback. Stakeholder Meetings Throughout the assessment process, meetings were conducted to establish a better understanding of activities performed by development partners and establish buy- in for scale- up plans. 5

16 High- level Findings While the needs and challenges of each TI varied significantly, there were several common themes found in all of the TIs visited: o Faculty Recruitment and Retention The most common finding from the field visits was the difficulty TIs experienced in recruiting and retaining qualified staff to train students. While tutor to student ratios varied significantly, all TIs noted that the lack of tutors would be a significant bottleneck to scaling up training capacity in the future. TIs located in hard- to- reach rural areas have particular difficulty recruiting and retaining qualified staff, noting long distances to trading centres and good schools for their children as significant motivating factors for leaving. Further, CHAM TIs have been over- dependent on MOH seconded tutors and have not been able to incentivize tutors to sign long- term employment contracts with their respective proprietorships, leading to high turnover of staff. o Practical Sites Given the significant role of clinical instruction as part of nursing/midwifery education, it was discovered that the logistics and planning around clinical instruction was one of the most significant bottlenecks to providing quality education to students and increasing training capacity. Given increased student intakes over the past several years, TIs have found providing clinical instruction at health facilities in the vicinity insufficient. Further, not enough health facilities meet NMCM guidelines to qualify as effective clinical learning sites. As a result, TIs have had to transport students to hospitals in different districts in order for students to obtain their required clinical case hours. Renting appropriate accommodation for students has further proven to be a significant logistical and financial burden for these TIs. o Learning Resources Most TIs noted a lack of textbooks, computers and internet access for students as a significant impediment to improving training quality. Teaching aids for faculty were also in short supply. TIs stated that in order for scale- up not to negatively impact learning standards that learning resources and teaching aids needed to increase for current and future students o Accommodation Infrastructure Many of the TIs, particularly CHAM TIs, have benefited from new infrastructure, including new hostels, provided under the EHRP. However, TIs located in rural and peri- urban 3 areas will require additional hostels to accommodate any new student intakes. Previously, due to a recent student fee subsidy freeze, TIs offered students the option of residing off- campus as non- residential students and students lived at home or with relatives and commuted to 3 A peri- urban area is one that is directly adjacent to an urban area 6

17 their respective TIs for classroom instruction. However they were treated as resident students during clinical placements and provided allowances, accommodation and meals. At the time of the field visits, approximately 8 students across all TIs were non- residential students. TIs noted that use of non- residential students would not be as ideal as housing students on- campus, however increased teaching staff, learning and transportation resources would compensate for any losses in training quality due to the use of non- residential students. o o Maintenance and Security Lack of physical security around TI campuses and insufficient resources for maintenance activities have had a negative impact on existing infrastructure. Some TIs lack security fences, resulting in stolen property and vandalized equipment as well as compromising student security. Many TIs lack the expertise or resources for maintaining existing infrastructure and equipment regularly, diminishing quality of training and student life and resulting in the need for the replacement of costly infrastructure and equipment. Teaching and Other Infrastructure Along with new hostels as part of the EHRP, many TIs received new and refurbished classrooms, skills labs, kitchens and dining halls. The field visits established that this new infrastructure was sufficiently spacious and of high quality, however older infrastructure required refurbishment and upgrades. The field visits also established that there were opportunities to maximize classroom and skills lab space upon review of TIs academic calendars where students were off campus at clinical placements for the majority of the school year. Functioning water supply facilities and back- up power generators were lacking at many TIs, and are a high priority for those in hard- to- reach areas. o Qualified Candidates Almost all TIs surveyed noted that they receive significantly more applications from qualified applicants than the number of available student spaces. The number of students meeting the minimum qualified standards far exceeds the number of available training posts. This presents a significant access to education challenge in Malawi. 7

18 Analysis Targets Scale- up targets for this operational plan were established by the gap between the current number of employed nurse/midwives in Malawi and the current staffing establishments (adjusted for population growth). In order to eliminate this gap within twenty years, nurse/midwifery TIs would need to double their current maximum training capacity by 26. In addition, as the lack of further in- service training has negatively impacted the retention of nurse/midwives, it was decided that in- service training would also undergo a scale- up over the five- year period. The linear, five- year scale- up period provides sufficient time for the required nurse tutors to be trained, and necessary infrastructure additions to be built. Further, this phased in approach would enable the country to financially plan to be able to absorb these new HCWs into the public healthcare system when they graduate. Malawi would reach the target health worker staffing levels for nurse/midwives by 224, approximately eight years after doubling intake, which is expected to be complete in 26 (Figure ). Assuming the staffing establishment for nurse/midwives remains static in this time period, staffing levels would be achieved even sooner, in 29 (Figure 2). Figure : Impact of Doubling Nurse/Midwifery Training Capacity vs. Staffing Establishment (Adjusted for Population Growth) 25, 2, INTERVENTION: TARGET ACHIEVED IN 224 A focused intervention to dramatically increase the number of nursing students enrolling in training programs will add an additional 9,99 nurses to the workforce by 22, above and beyond the,962 nurses entering the workforce without any intervention INTERVENTION 2,6 Nurses and Midwives 5,, NO INTERVENTION: STATUS QUO,962 Nurses and Midwives 5, INTERVENTION STARTS IN 2 Maximizing existing capacity of training institutions, doubling the number of first- year students for NMT, DN, and BSCN programs, and increasing graduation rates for all programs to at least 95% National Workforce Baseline National Workforce Intervention Target 8

19 Figure 2: Impact of Doubling Nurse/Midwifery Training Capacity vs. Staffing Establishment (Static) Recommended Standards The following standards were used in determining the needs for TIs. The NMCM has established some minimum quality standards, but where existing NMCM standards did not exist, proposed standards were set for the purposes of the analysis: o o o o o o o Teaching Staff o Tutors: tutor per 5 students o Clinical Instructors: clinical instructor per students in general training and clinical instructor per 5 students in midwifery training Classroom o To maintain consistency with :5 teacher to student ratio, classrooms should comfortably accommodate 5 students Accommodation o Two students per room, two beds per room o tutor house per nurse tutor in rural areas, housing allowance for those in urban areas Library o Seating for 25% of the student population Books o Set of textbooks required in the curriculum per student Computers o Provide computers for at least 5% of the student population Dining 9

20 o o Provide seating capacity for 25% of total student body Vehicles o Provide seat buses for every three groups of 5 students Classroom/Clinical Facility Optimization As previously noted, from the field visits it was apparent that existing classrooms were of an appropriate size and of high quality. Given the academic calendars with a heavy focus on clinical practice, these classrooms were not fully utilized. The field visits also established that TIs were enrolling between 6- students into one class, thereby breaching the 5- student maximum class size recommendation by the NMCM. As a result, an analysis was conducted to determine how to maximize use of existing classrooms while ensuring students are not trained in groups larger than 5 to adhere to the NMCM standard and improve general training quality. The analysis concluded that TIs that incorporated a staggered intake of students could maximize existing classroom space and minimize overlap of clinical placements while increasing student intake. Academic calendars typically required heavy classroom instruction in the first year (particularly the first half of the year). For second, third and fourth year (where applicable) students, a significant part of the latter half of the year was spent at clinical sites. The analysis incorporated academic calendars for the TIs and existing curricula requirements (to ensure required theory and clinical hours were still being met). Further, the NMT syllabus had recently been changed by the NMCM, requiring only 37 weeks of classroom instruction over the three- year program. A training schedule was developed in collaboration with NMCM to be used as a guideline for TIs in adopting the revised NMT syllabus. The following adjustments to the academic calendars were therefore proposed, thus optimizing use of existing classrooms and minimizing additional classrooms required to scale- up: o KCN and Malawi College of Health Sciences Blantyre Campus Upgrading Programs commence in the first semester with Generic Programs commencing in the second semester o NMT Programs (see Appendix 2) Two NMT intakes performed during the year, 6- months apart This model was included as a suggestion as opposed to being integrated into the operational plans given the administrative and academic challenges some schools may face in implementing a staggered- intake model This approach ensured that the scale- up plans were consistent with existing NMCM requirements and that limited resources could be directed to higher priority needs such as more teaching staff, learning resources, transportation options and accommodation. Determining Teaching Requirements The current standards set by NMCM require one tutor for 5 students and one clinical instructor for five students. This can result in either understaffing given the prescribed tutor to student ratio, or over- 2