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

21 staffing given the prescribed clinical instructor to student ratio. The analysis thus sought to analyze tutor workload to provide a more effective means of measuring the required staffing levels at each TI. The analytical model utilizes the following factors in determining optimal teaching staff requirements: o o o o Teaching hours/week for tutors and clinical instructors established from TI visits Required hours as established by NMCM syllabus (for NMT programs) or NMCM approved curricula (for remaining programs) Maximum tutor to student ratio (:5) and clinical instructor to student ratio (:) Maximum number of groups of 5 students at a time during a typical year The above factors combined to determine the optimal teaching requirements for nursing/midwifery students. Non- Residential Students by Region Type The operational budgets produced by the analysis tool show three different options for scale- up and provide a minimum requirement for each TI based on whether it is located in an urban, peri- urban or rural setting. The proposed standards suggest all new students at TIs in rural settings are required to reside on campus (full residential), half of new students at TIs in peri- urban settings are, at minimum, required to reside on campus (half- residential) and new students at TIs in urban settings may be entirely non- residential. The following TIs were categorized as follows: Urban: Kamuzu College of Nursing (Lilongwe and Blantyre campuses), Malawi College of Health Sciences (Lilongwe, Blantyre and Zomba campuses), Mzuzu University (Mzuzu), Ekwendeni College of Nursing (Mzuzu), St. John s College of Nursing (Mzuzu), St. John of God College of Nursing (Mzuzu) and Dae Yang College of Nursing (Lilongwe) Peri- Urban: St. Lukes College of Nursing (Zomba), St. Joseph s College of Nursing (Zomba), Mulanje Mission College of Nursing (Mulanje) Rural: Holy Family College of Nursing (Phalombe), Trinity College of Nursing (Nsanje), Nkhoma College of Nursing (Lilongwe), Malamulo College of Health Sciences (Thyolo) Looking Forward: Increasing TI Capacity Through the interviews conducted during the field visits, it was clear that TIs fully understood the significant role they play in improving the state of Malawi s health system by producing highly qualified HCWs. Despite undergoing significant infrastructure upgrades and scaling up training capacity over the past several years, TIs remain committed to the important responsibility of continuing to train more nurse/midwives for Malawi. However, this commitment comes with the important requirement that sufficient teaching staff, learning resources and infrastructure is provided where necessary to ensure that quality can be maintained or improved in conjunction with larger student intakes. 2

22 With funding and resources in limited supply, TIs will need to look for creative solutions to scale- up training capacity to meet the significant demand for nurse/midwives in Malawi. This will mean directing limited funds to areas that increase training capacity and improve training quality, while evaluating areas for potential cost- savings. Further, government can take the lead in lobbying the private sector through District Assemblies and other mechanisms to identify potential business opportunities for private businesses to assist in meeting scale- up goals (i.e. establishment of rental accommodation for students at clinical sites, provision of security service to TIs). Using the Excel model to analyze information collected during the TI assessments and expert interviews, detailed and costed scale- up plans were created for each individual nursing/midwifery TI in Malawi and are included in Annex 3. 22

23 System- level Recommendations Challenge. Limited pool of qualified teaching staff at nursing TIs 2. Difficulty retaining faculty from available pool of teaching staff due to lack of effective incentives 3. Limited capacity at TIs, particularly in hard- to- reach areas, impacts ability to scale- up 4. Limited capacity at clinical learning sites negatively impacts ability to scale- up 5. Limited access to sophisticated learning resources and learning aids Recommendation Increase training capacity of existing Post- Basic Nursing Program at KCN Pilot distance- learning Post- Basic Nursing Program at KCN, leveraging recently acquired e- learning resources and training Create an upgrading Master s Program for nurse tutors to entice higher enrolment in training of nurse tutors Create a fast- track upgrading program for clinical instructors to the Post- Basic Nursing Program to increase pool of qualified candidates to become nurse tutors Transition tutors currently seconded from MoH to be employed under CHAM proprietors Build nurse tutor housing in TIs located in hard- to- reach areas Implement a hardship allowance package for tutors in hard- to- reach areas Provide housing allowances to nurse tutors in urban areas with expensive accommodation options Ensure nurse tutors receive 52% salary top- ups consistent with practicing counterparts Improve accessibility to continuing professional development courses held at district hospitals for nurse tutors Work with TIs to adjust academic calendar, consistent with existing curricula, to maximize use of existing classrooms, skills labs and libraries Provide administrative support to TIs to absorb staggered intakes of students (i.e. pre- service programs begin in October, in- service programs begin in April) Promote use of non- residential students at urban and peri- urban TIs to maximize student enrollment to scale- up capacity quickly Conduct TI maintenance and security assessment to identify opportunities to better maintain new and existing infrastructure and establish recommendations to improve safety of students at TI assets Procure additional vehicles for TIs to transport students to clinical sites NMCM should assess and revise existing guidelines used to help TIs select appropriate clinical training facilities to expand the number of learning sites Identify rental options or temporary housing for students and clinical instructors at learning sites Establish two- month clinical instructor curricula for health workers at practical sites to improve clinical instruction skills and ensure participants are prioritized clinical instructors for TIs to engage Ensure all TIs can provide internet access to students

24 6. Weak management, administration and reporting capabilities 7. Limited central capacity at MoH and CHAM to manage scale- up activities 8. Specialization courses do not always lead to higher compensation packages, limiting incentive for nurse/midwives to upgrade their skills 9. Over- dependence on government funding mechanisms for operational and expansion funds Continue to support capacity- building activities that improve management and administrative capacity of principals and support staff Establish a standardized reporting template for number of applicants, enrollments, progression, performance and attrition factors with mandatory reporting requirements to MoH and CHAM Provide salary support to posts at MoH and CHAM to help TIs coordinate scale- up activities Provide resources (computers and transportation) to MoH and CHAM to manage scale- up activities and intensify joint monitoring and evaluation activities Work with the Department of Public Service Management to provide pay- grade increases for any formal further qualification and specialization courses Conduct forums with private- sector entities to encourage investment in key operational and expansion costs for TIs training critical HCWs as part of their corporate social responsibility objectives Phase in partial financial student contributions to finance own student fees resulting in cost- savings which can be used to enroll more students or train additional tutors 24

25 Prioritization by Cost- Effectiveness The operational budgets produced by the analysis tool provide five- year costed plans for each TI, which can be further synthesized to determine cost of scale- up on a per- student basis. Given the severity and urgency of Malawi s HRH crisis, TIs that can scale- up more cost effectively (as a result of sufficient existing classroom space and adequate teaching staff) on a per- student basis should be prioritized in case of securing only part of the total operational funds required. The analysis thus proposes scale- up of TIs based on the formula: Scale- up Cost per New HCW = Total One- off Costs and Recurring Costs (2-26) / Net New HCWs Produced (24-28) The TIs are thus prioritized based on cost- effectiveness as follows: HCWs*Produced*(24. Scale.up*Costs*(USD*'s) 28) Rank School*Name PerNew HCW PerTI Culimative Total NewHCWs byti TotalNew HCWs MCHS&Zomba &&&&&&&&&&&& 6.7 &&&&&&&&&&& 2,399 &&&&&&&&&&& 2,399 &&&&&&&&&&&&& 389 &&&&&&&&&&&&& Kamuzu&College&of&Nursing &&&&&&&&&&&& 7.4 &&&&&&&&&&& 3,28 &&&&&&&&&&& 5,68 &&&&&&&&&&&&& 466 &&&&&&&&&&&&& Dae&Yang &&&&&&&&&&&& 7.3 &&&&&&&&&&&&& 37 &&&&&&&&&&& 6,5 &&&&&&&&&&&&&&& 52 &&&&&&&&&&&&& 97 4 MCHS&Blantyre &&&&&&&&&&& 2.95 &&&&&&&&&&&&& 83 &&&&&&&&&&& 6,854 &&&&&&&&&&&&&&& 62 &&&&&&&&&&&&& Mulanje&Mission&College&of&Nursing &&&&&&&&&&&& 8.23 &&&&&&&&&&&,967 &&&&&&&&&&& 8,82 &&&&&&&&&&&&& 239 &&&&&&&&&&&,28 6 Ekwendeni&College&of&Nursing &&&&&&&&&&& 4.36 &&&&&&&&&&&&& 99 &&&&&&&&&&& 9,8 &&&&&&&&&&&&&&& 69 &&&&&&&&&&&,277 7 St.&Joseph's&College&of&Nursing &&&&&&&&&&&& 8.69 &&&&&&&&&&& 2,678 &&&&&&&&& 2,489 &&&&&&&&&&&&& 38 &&&&&&&&&&&,585 8 Malamulo&College&of&Health&Sciences &&&&&&&&&&&& 9.77 &&&&&&&&&&&,55 &&&&&&&&& 3,994 &&&&&&&&&&&&& 54 &&&&&&&&&&&,739 9 Mzuzu&University &&&&&&&&&&& 2.3 &&&&&&&&&&&&& 8 &&&&&&&&& 4,794 &&&&&&&&&&&&&&& 66 &&&&&&&&&&&,85 St.&Luke's&College&of&Nursing &&&&&&&&&&&.75 &&&&&&&&&&&,869 &&&&&&&&& 6,662 &&&&&&&&&&&&& 59 &&&&&&&&&&&,964 Trinity&College&of&Nursing &&&&&&&&&&& 4.6 &&&&&&&&&&& 2,979 &&&&&&&&& 9,64 &&&&&&&&&&&&& 24 &&&&&&&&&&& 2,68 2 Nkhoma&College&of&Nursing &&&&&&&&&&& 4.6 &&&&&&&&&&& 2,96 &&&&&&&&& 22,547 &&&&&&&&&&&&& 99 &&&&&&&&&&& 2,367 3 Holy&Family&College&of&Nursing &&&&&&&&&&& 2.48 &&&&&&&&&&& 3,7 &&&&&&&&& 25,654 &&&&&&&&&&&&& 249 &&&&&&&&&&& 2,66 4 St.&John's&College&of&Nursing &&&&&&&&&&& 5.77 &&&&&&&&&&&,68 &&&&&&&&& 27,263 &&&&&&&&&&&&& 2 &&&&&&&&&&& 2,78 Note that at the time of preparing this document, St. John of God and MCHS- Lilongwe have been excluded from this analysis as these schools do not train pre- service students and therefore will not generate new HCWs between 2 and 28. Overall Resource Needs Total investments of approximately 27.5 million would be required to equip TIs with the appropriate infrastructure, teaching staff and equipment. The execution of scale- up plans is to take place over a 5- year period. The charts below illustrate costs by staffing needs (Figure 3 below), costs by infrastructure needs (Figure 4 below), costs over time (Figure 5 below), as well as costs by government institutions and CHAM TIs (Figure 6 below). 25

26 Figure 3: Cost (USD) of Staffing Needs 2,229,94 37 Tutors (43%) Skills Lab Instructors (7%) Clinical Instructors (5%) Figure 4: Costs (USD) by Infrastructure Type 3,534 6,,5,9 5,328 2,465, Classrooms (6%) Skills Labs (4%) Office Blocks (8%) Libraries (6%) Dining Halls (4%) Tutor Houses (%) Student Housing (24%) Vehicles (27%) 26

27 Figure 5: Costs (USD) Over Time 9, 8, 7, 7,867 Higher expected costs in Year due to relatively higher investments in infrastructure and vehicles to prepare TIs for scale- up. 6, 5, 4, 4,544 3,75 3,378 3,585 4,347 3, 2,, Year Year 2 Year 3 Year 4 Year 5 Year 6 Costs (USD) Figure 6: Total Costs (USD) by Government and CHAM Institutions 7,396 2,28 Government (27%) CHAM (73%) 27

28 Next Steps. Consult with the MoH Planning Department, the Department of Public Service Management and the Ministry of Finance to review scale- up targets as they relate to the funded establishment. Adjust operational plans as necessary 2. Work to solidify training standards where current standards do not exist (i.e. computers, textbooks) to ensure all TIs maintain training quality standards in line with increasing student intakes 3. Disseminate the final version of the National Training Operational Plan to stakeholders who participated in the assessment, partners and all relevant government departments, particularly the Ministry of Education, involved in training nurse/midwives 4. Mobilize resources, either bilaterally or through the SWAp funding mechanism to fund training operational plans 5. Work with Government of Malawi to establish a working forum between MoH, MoE, CHAM and regulatory bodies to coordinate all scale- up decisions relating to Tis 6. Identify opportunities to establish new TIs and utilize NTOP approach in needs assessment 7. Establish simple guidelines for TIs to access and utilize funding and resources from Government of Malawi 28

29 Appendix : TI Questionnaire Training Insitution Field Questionnaire Name of School Name of Principal Proprietor (MoH/CHAM) Student Intake Month(s) Date of Visit District A. Program Overview Program Name (Designation) Years Nurse Midwife Technician (NMT) 3 Midwife Technician (MT) Psychiatry Nurse Technician (PNT) Community Health Technician (CHNT) Registered Nurse (DN) 3 Registered Psychiatry Nurse (RPN) 2 Registered Nurse Midwife (UDN) 2 Professional Registered Nurse (BSCN) 4 Professional Registered Nurse (UBSCN) 2 Registered Midwife (UCM) Masters in Nursing (MSCN) 2 Doctorate in Nursing (PhD) 4 Offered? Y/N Target Intake? B. Enrollment and Graduation Note: /2 columns used to capture two cohorts where applicable. Applicants Programs Offered Select Program Number of Total Qualified Applicants (Historical) Total Total First- Year Enrollment Complete if necessary to illustrate existing double- intake model Programs Offered Select Program Number of First Year Students Enrolled Total Total 29

30 Graduates Programs Offered Select Program Number of Graduates Total Total Total Student Enrollment (Male/Female Breakdown) Add additional tables if more than one program as necessary Select Program Year Year Year 2 Year 3 Year 4 Total Applicable Year Number of Students M F Total M F Total M F Total M F Total M F Total C. Current Staffing Staff Categories FT Staff PT Staff On Leave Nurse Tutors (BSCN) Nurse Lecturers (MScN) Nurse Lecturers (PhD) Assistant Tutors Clinical Instructors Skills Lab Instructors Finance and Admin Staff Drivers Other Staff (cooks, cleaning, etc) Total General Questions: Q. How many admin staff (i.e. principal, vice principal) currently double as tutors? Q2. How many nurse tutors also work as clinical instructors? Q3. What strategies has the school employed to increase contact hours during clinical instruction aside of staff increases? 3

31 D. Infrastructure Existing Infrastructure Item Lecture Theatre Lecture Hall Classroom Skills Lab Library Hostel beds Admin Offices Nurse Tutor Housing Kitchen/Dining Hall Other (specify) Units Avg Capacity Target Infrastructure Item Lecture Theatre Lecture Hall Classroom Skills Lab Library Hostel beds Admin Offices Nurse Tutor Housing Kitchen/Dining Hall Other (specify) Units Avg Capacity Infrastructure Planned or In Progress Item Units Avg Capacity Donor Expected Delivery Select.. Select.. Select.. Select.. Select.. Select.. E. Accommodation and Transportation Clinical Sites Clinical Site Name Distance Students Daily Transport or Accommodation? Site Specialization? Visits by Tutors 3

32 Hostel Breakdown Housing Block Capacity Total Students Students per Room Males Females Vehicles Type Capacity Accommodation Preferences Q. How many non- residential students are enrolled? Q2. How many residential, no- food students are currently enrolled? Q3. How do non- residential students get to their clinical sites. How is this organized and paid for by the colleges? Q4. On average, how much more does it cost to transport a non- residential student than a residential student to a clinical site? Q5. What impact on quality would students were living off- campus cause? Q6. Has the school considered options for evening classes? F. Finances Fiscal Year End Obtain Financial Statements for 28/29 Fiscal Year, 29/2 Fiscal Year and 2 Expected Budget (if available) 32

33 G. Scheduling Q. How efficient is the current school schedule currently? Q2. What scheduling strategies can you think of that could increase capacity with limited changes to infrastructure? Q3. Approximate teaching hours: Program Program Program Average hours / week of theory instruction by tutor Average hours / week of lab instruction Average hours / week of practical site instruction by clinical instructor Average hours / week of other instruction Obtain Master Plan or Clinical Rotation from TI Obtain Copy of Training Program Curricula from TI H. Retention Q. How many nurse tutors have renewed their contracts beyond the 2- year secondment? Q2. What are the most popular reasons for nurse tutors leaving immediately after the 2- year secondment? Rank Most (5) to Least () Common Reasons for Leaving: Distance from Family Salary Dissatisfaction Dispute with School Poor Performance Did not enjoy teaching Q3. How many lecturers retired, resigned or were dismissed in the following years? Lecturers Retired Lectures Resigned Lecturers Dismissed Q4. How many students dropped out (29, 28, expected in 2) for the following reasons? Reason Student Fees Academic Performance Learning Environment Living Conditions Medical Reasons Other (specify) Total Expected Q5. What strategies are employed by the school to reduce drop- outs? 33

34 I. General Qualitative Assessment The following are directed to educators and administrators at the school to provide a high- level assessment on education quality. Q. Is the dean or principle of the school a nurse? Yes: No: Q2. When was the last time a committee reviewed the curriculum? Does your staff have sufficient expertise to review curriculum? Q3. Appropriate textbooks available to support the curriculum?yes: No: If no, which areas are lacking the most? Q4. What percent of faculty have expertise in education? Q5. Is there regular faculty continuing education? When and how is it administered? Q6. List types of faculty continuing education courses: Q7. How are faculty members evaluated? Q8. Do faculty members have access to online research? Yes: No: Q9. How are student evaluated with regards to theoretical knowledge? How are they evaluated with regards to clinical placements? Q. Do students have access to online research? Yes: No: Q. Is HIV/AIDS content integrated into all levels of course work, or is it a separate course? Q2. If you could prioritize three critical areas of need, what would they be? 34

35 Q3. What are the school's three greatest areas of strength? Q4. On average, what percent of the time are students supervised in the clinical environment? Q5. How many functioning computers does the school have? J. Informal Student Survey The following are questions to be rated as E xcellent, G ood, A verage, P oor or F requent, S ometimes, R arely, N ever where applicable by three to five respondents. Lectures R R2 R3 R4 R5 Q. How strong is the relationship between in- class theory and your clinical learning activities? Q2. How would you rate the sufficiency of your after class contact time with tutors? Q3. How would you rate your tutor's knowledge of the curriculum? Clinical Learning Environment Q4. How would you rate the overall quality of your clinical instruction? Q5. How would you rate your level of exposure to patients at clinical sites? Q6. How well do your clinical placements prepare you for your career as a nurse? Q7. What percent of your time in clinical placements are you supervised? Learning Materials Q8. How would you assess the sufficiency of learning materials provided? Q9. How would you assess the relevancy of learning materials provided? Q. How would you rate access to online research or complementary learning materials provided? Skills Labs Q. How frequently do you access the skills labs? Q2. How adequately do the skills labs prepare you for your clinical learning? Q3. How many hours/week do you spend in the skills lab? 35

36 General - Compiled Student Responses Q4. What would you say the school's greatest strengths are? Q5. What would you say the school's weaknesses are? Q6. Do you have any general suggestions to improve the school? Q7. What is the level of difficulty you are experiencing in paying total student fees? What percent remains outstanding? R R2 R3 R4 R5 Difficulty % outstanding 36

37 Appendix 2: Staggered Intake Example Start of First Semester Clinical Instruction Classroom Instruction Holiday/No School Exam Period SINGLE INTAKE Academic Week # Month October November December January February March April May June July August September T T T T T T T T T T T T T H H C C C C C C C C H H C C C C C C C T T T T T C C C C C C C C C C C C H H H Y NMT T T T T T T T C C C C C C H H C C C C C C T T T T H H C C C C C C C C C C C C C T T T T H H C C C C C C Y2 NMT T T T T T C C C C C C C C H H H C C C C C C T T T T H H C C C C C C C C C C H H C C C C C C C C C C C C Y3 NMT DOUBLE STAGGERED INTAKE Academic Week # Month October November December January February March April May June July August September T T T T T T T T T T T T T H H C C C C C C C C H H C C C C C C C T T T t t C C C C C C C C C C C C H H H YA NMT C C C C C T T T t t C C C C C C C C C C C C H H H T T T T T T T T T T T T T H H C C C C C C C C H H C C YB NMT T T T T T T T C C C C C C H H C C C C C C T T T T H H C C C C C C C C C C C C C T T T T H H C C C C C C Y2A NMT C C C C C C C C C C C C C T T T T H H C C C C C C T T T T T T T C C C C C C H H C C C C C C T T T T H H Y2B NMT T T T T T C C C C C C C C H H H C C C C C C T T T T H H C C C C C C C C C C H H C C C C C C C C C C C C Y3A NMT H C C C C C C C C C C H H C C C C C C C C C C C C T T T T T C C C C C C C C H H H C C C C C C T T T T H Y3B NMT Developed with input from NMCM, the above training calendar for the NMT program suggests two intakes should be performed approximately six months apart (end of September and end of March). Doubling the intake in this way ensures that instead of six classrooms being required for six streams of students (two cohorts per year), a maximum of only four classrooms are needed at any given time. Further, the above model matches required classroom and clinical instruction hours to the NMT syllabus. 37

38 Appendix 3 Training Opera+onal Plans Work Plans and Budgets for Scale- up of Nurse Training Ins+tu+ons in Malawi

39 Illustrave Example Appendix 3 September 2 Opera&ng Budget One- off and recurring costs required to meet scale- up target of doubling current intake capacity. Note that opera+ng budgets focus on expense items with individual unit costs greater than 5US. Insignificant items have been les out for presenta+on purposes. Residen&al Op&on Based on the loca+on of the TI (urban, peri- urban, rural), opera+ng budget recommends the minimum accepted scale- up requirement for student and tutor housing with a check- mark. Total Recommended Cost The one- off infrastructure and transporta+on costs plus the cost of the recommended accommoda+on op+on plus the necessary recurring costs. Impact Chart Illustrates the number of graduates between Grey bars are es+mates of student output that are not impacted by scale- up ac+vi+es. Coloured bars are es+mates of student output that are directly impacted by scale- up ac+vi+es. One- off Costs (USD 's) (USD s) Category Unit Cost Total Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single- level library Build/update dining facilities Buy new computers Transportation # Purchase 32- seat vehicle Accommodation Option - Non Residential # No activities N/A Total One- Time Costs Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs ,48 Recurring Costs (USD 's) Category Unit Cost Total Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended net new nurses vs. 2 baseline Net New Nurses Es+mated number of new nurses graduated as a result of scale- up ac+vi+es compared to 29/2 graduate levels.

40 Illustrave Example Appendix 3 September 2 Summary Increase student intake to 46 in 2, 57 in 23 and 8 in 26 Produc+on increases to 49 in 24, 6 in 26 and 73 in 28 and thereaser Es+mated total scale- up cost (USD): 869, Total nurses produced 24-28: 34 Net new nurses produced (vs. baseline): 69 Training Ins&tu&on Profile Located in Mzuzu (urban) operated by Proprietor (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire skills lab instructor and clinical instructor in 2 Hire add l skills lab instructor in 22 Hire add l clinical instructor in each of 22, 23 and 25 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure Build new classroom in each of 23 and 25 Build new office block in 22 Build new library in 26 Vehicles & Equipment Purchase 2 vehicles in each of 2 and 22 Purchase 9 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 2,59 Scale- up cost effec+veness rank: Accommoda&on Op&on - Minimum Recommended New residences for new nurse tutors and new students not essen+al given urban se_ng Classroom and Clinical Site Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 2 to Resul+ng es+mated savings: 53, in 25 Last Update (USD s) Date the informa+on on the Training Opera+onal Plan (TOP) was last updated. Summary Student intake and produc+on indicators as well as total scale- up cost. Profile Basic profile of training ins+tu+on and type of nurses trained. Key Ac&vi&es Summary of key ac+vi+es required to achieve scale- up target (double current maximum intake capacity) organized by Faculty, Accommoda+on, Other Infrastructure and Vehicles & Equipment Addi&onal Considera&ons Shows the TI s es+mated cost per net new nurse graduated based on total costs (2-26) divided by net new nurses graduated (24-28). Clarifies the minimum accepted accommoda+on op+on required for scale- up Where classroom costs are significant, illustrates poten+al cost- savings thru reduc+on in classrooms through use of a staggered intake. These savings are op+onal but are not included in the budget unless otherwise noted.

41 Scale- up Cost Summary Appendix 3 September 2 (USD (USD s) s) Oneoff'Costs'(USD''s) Category Type 'Unit'Cost' Total Faculty # Hire%additional%teaching%staff Recruiting %%%%%%%%%%%%%%.5 33 %%%%%%%%%%% %%%%%%%%%%%%% 7 2 %%%%%%%%%%% 23 %%%%%%%%%%% 2 26 %%%%%%%%%%% 3 33 %%%%%%%%%%% %%%%%%%%%%%%%%%%%%% 34 Infrastructure # Build%new%classroom Classroom %%%%%%%%%%%%% %%%%%%,4 2 %%%%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%%%% 456 %%%%%%%%% %%%%%%%%%%%%%%%% 3,534 Build%new%skills%lab Skills%lab %%%%%%%%%%%%% %%%%%%%%% 63 2 %%%%%%%%%%% 34 2 %%%%%%%%% 34 2 %%%%%%%%% 34 %%%%%%%%%% G %%%%%%%%%% G 5 %%%%%%%%%%%%%%%%,5 Build%new%office%block%(%tutors) Office %%%%%%%%%%%. 4 %%%%%%%%% 4 8 %%%%%%%%%%% 8 %%%%%%%%% 3 %%%%%%%%% 3 2 %%%%%%%%% 2 %%%%%%%%% 9 %%%%%%%%%%%%%%%%,9 Build%new%singleGlevel%library Single%level%library %%%%%%%%%%% 7. %%%%%%%%%% G %%%%%%%%%%% 7 %%%%%%%%%% G 2 %%%%%%%%% 24 %%%%%%%%% 7 %%%%%%%%%% G 4 %%%%%%%%%%%%%%%%%%% 428 Build%new%multiGlevel%library MultiGlevel%library %%%%%%%%%%% 24. %%%%%%%%% 24 %%%%%%%%%%%% G 2 %%%%%%%%% 428 %%%%%%%%% 24 %%%%%%%%%% G %%%%%%%%%% G 4 %%%%%%%%%%%%%%%%%%% 856 Build/update%dining%facilities Dining%hall %%%%%%%%%%% 7. %%%%%%%%% 7 %%%%%%%%%%% 7 %%%%%%%%% 7 %%%%%%%%% 7 2 %%%%%%%%% 24 3 %%%%%%%%% 32 9 %%%%%%%%%%%%%%%%%%% 963 Buy%new%computers Computer %%%%%%%%%%%%%%. 29 %%%%%%%%% %%%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%%%%%%%%% 252 Transportation # Purchase%32Gseat%vehicle Bus %%%%%%%%%%% %%%%%% 2,86 8 %%%%%%%%%%% %%%%%%%%% 6 4 %%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%%%%%%%%%%% 6, Aggregate'of'Acommodation'Option'''Non'Residential # No%activities N/A N/A %%%%%%%%%% G %%%%%%%%%%%% G %%%%%%%%%% G %%%%%%%%%% G %%%%%%%%%% G %%%%%%%%%% G %%%%%%%%%%%%%%%%%%%% G Total'OneTime'Costs '''''' 5,466 '''''''' 2,85 '''''',83 '''''',79 '''''',5 '''''',825 '''''''''''''' 5,72 Aggregate'of'Accommodation'Option'2''Half'Residential # Build%new%student%accomm.%(5%beds) Hostel%block %%%%%%%%%%% %%%%%%,332 4 %%%%%%%%%%%% G 3 %%%%%%%%% %%%%%%,332 3 %%%%%%%%% %%%%%%, %%%%%%%%%%%%%%%% 5,994 Build%new%tutor%accomm. Tutor%house %%%%%%%%%%%%% %%%%%% 2,253 %%%%%%%%%%% 53 6 %%%%%%%%% 38 7 %%%%%%%%% %%%%%%%%% 424 %%%%%%%%% %%%%%%%%%%%%%%%% 4,452 Total'OneTime'Costs '''''' 9,5 '''''''' 3,38 '''''' 3,3 '''''' 3,395 '''''' 2,757 '''''' 3,96 '''''''''''''' 25,68 Aggregate'of'Accommodation'Option'3''Full'Residential # Build%new%student%accomm.%(5%beds) Hostel%block %%%%%%%%%%% %%%%%% 2,997 6 %%%%%%%%,998 7 %%%%%% 2,33 7 %%%%%% 2,33 6 %%%%%%,998 8 %%%%%% 2, %%%%%%%%%%%%%%% 4,39 Build%new%tutor%accomm. Tutor%house %%%%%%%%%%%%% %%%%%% 4,55 2 %%%%%%%%,6 2 %%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%,66 68 %%%%%%%%%%%%%%%% 8,94 Total'OneTime'Costs '''' 2,968 '''''''' 5,99 '''''' 4,78 '''''' 4,739 '''''' 4,346 '''''' 5,655 '''''''''''''' 38,395 Aggregate'of'Recommended'Accommodation'Option # Build%new%student%accomm.%(5%beds) Hostel%block %%%%%%%%%%% %%%%%%, %%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%%%%%%%%%%% 5,328 Build%new%tutor%accomm. Tutor%house %%%%%%%%%%%%% %%%%%%%%% %%%%%%%%%%% %%%%%%%%% 22 %%%%%%%%%%% 53 %%%%%%%%% 53 9 %%%%%%%%% %%%%%%%%%%%%%%%% 2,465 Total'OneTime'Costs '''''' 7,4 '''''''' 3,94 '''''' 3,24 '''''' 2,64 '''''' 2,696 '''''' 3,3 '''''''''''''' 22,965 Recurring'Costs'(USD''s) Category Type Unit'Cost Total Faculty # (USD s) Salary%for%add'l%tutor Annual%salary %%%%%%%%%%%%%% %%%%%%%%% 53 4 %%%%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%%%%%%%%%%%,94 Salary%for%add'l%skills%lab%instructor Annual%salary %%%%%%%%%%%%%% %%%%%%%%%%% 47 7 %%%%%%%%%%%%% 5 8 %%%%%%%%%%% 53 8 %%%%%%%%%%% 53 9 %%%%%%%%%%% 56 9 %%%%%%%%%%% 56 9 %%%%%%%%%%%%%%%%%%% 37 Salary%for%add'l%clinical%instructor Annual%salary %%%%%%%%%%%%%% %%%%%%%%% %%%%%%%%%%% 32 2 %%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%%%% %%%%%%%%%%%%%%%% 2,229 Total'Recurring'Costs '' 33 ''''''''' 467 '' 66 ''''''''''' 63 '' 86 ''''''''' 68 '' 29 ''''''''' 774 '' 235 ''''''''' 889 '' 268 '''''',46 '' 268 '''''''''''''''' 4,46 Total'Recommended '''''''' 27,424

42 Dae Yang College of Nursing Appendix 3 September 2 Summary Increase student intake to 2 in 2, 27 in 23 and 38 in 26 Produc+on increases to 2 in 24, 25 in 26 and 3 in 28 and thereaser Es+mated total scale- up cost (USD): 37, Total nurses produced 24-28: 43 Net new nurses produced (vs. baseline): 52 Training Ins&tu&on Profile Located in Lilongwe (urban) operated by Dae Yang Luke (CHAM) Trains Diploma Nurses (Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 6 tutors and 2 clinical instructors in 2 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure No addi+onal infrastructure required Vehicles & Equipment Purchase addi+onal vehicle in 2 Purchase 5 computers before 23 Provide textbooks for new and exis+ng students One- off Costs (USD 's) (USD s) Category Unit Cost Total Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single- level library Build/update dining facilities Buy new computers Transportation # Purchase 32- seat vehicles Accommodation Option - Non Residential # No activities N/A Total One- Time Costs Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs Recurring Costs (USD 's) (USD s) Category Unit Cost Total Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended 37 Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 7,3 Scale- up cost effec+veness rank: 3 Accommoda&on Op&on - Minimum Recommended Residences for new nurse tutors and new students not essen+al given urban se_ng Classroom and Clinical Site Op&miza&on Staggering intake not necessary given sufficient exis+ng classroom space available for scale- up plans 52 net new nurses vs. 2 baseline

43 Ekwendeni College of Nursing Appendix 3 September 2 Summary Increase student intake to 46 in 2, 57 in 23 and 8 in 26 Produc+on increases to 49 in 24, 6 in 26 and 73 in 28 and thereaser Es+mated total scale- up cost (USD): 99, Total nurses produced 24-28: 34 Net new nurses produced (vs. baseline): 69 Training Ins&tu&on Profile Located in Mzuzu (urban), proprietor- operated (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire skills lab instructor and clinical instructor in 2 Hire add l skills lab instructor in 22 Hire add l clinical instructor in each of 22, 23 and 25 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure Build new classroom in each of 23 and 25 Build new office block in 22 Build new library in 26 Vehicles & Equipment Purchase 2 vehicles in each of 2 and 22 Purchase 9 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Oneoff'Costs'(USD''s) (USD s) Category 'Unit'Cost' Total Infrastructure # Build&new&classroom &&&&&& 57. &&&&&&& 57 &&&&&&& 57 2 &&&&&& 4 Build&new&skills&lab &&&&&& 67. &&&&&&& 67 &&&&&&& 67 2 &&&&&& 34 Build&new&office&block&(&tutors) &&&&. &&&&& &&&&&& Build&new&single4level&library &&&& 7. &&&&& 7 &&&&&& 7 Build/update&dining&facilities Buy&new&computers Transportation Purchase&324seat&vehicle &&&& 7. &&&&&&&&. &&&& # 2 &&&&&&&&& 6 &&&&& 244 # &&&&&&&&& &&&&& 22 # # &&&&&&&&& # &&&&&&&&& 2 # &&&&&&&&& 2 # 3 &&&&&&& 4 &&&&&&&& &&&&&& 366 Accommodation'Option'''Non'Residential # No&activities N/A &&&&&&& 4 Total'OneTime'Costs Accommodation'Option'2''Half'Residential # ''''' 49 ''''' 249 '''''' ''''' 67 ''''''''' ''''''''' 2 '''''' 837 Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& 53. ''''' 49 ''''' 249 '''''' &&&&& 67 ''''' 333 ''''''''' ''''''''' 2 &&&&&& 67 &&&&&&& 4 ''',3 Accommodation'Option'3''Full'Residential # Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& 53. ''''' 49 ''''' 249 '''''' &&&&& 333 ''''' 5 ''''''''' ''''''''' 2 &&&&&& 333 &&&&&&& 4 ''',7 Recurring'Costs'(USD''s) Category Faculty Salary&for&add'l&tutor Salary&for&add'l&skills&lab&instructor Salary&for&add'l&clinical&instructor Total'Recurring'Costs Total'Recommended Unit'Cost Total # &&&&&&&& 5.68 &&&&&&&&& 6 &&&&&&&&& 6 3 &&&&&&& 7 3 &&&&&&& 7 3 &&&&&&& 7 3 &&&&&&&& 62 &&&&&&&& 2.96 &&&&&&&&& 3 2 &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&& 33 &&&&&&&& &&&&&&&&& 6 3 &&&&&&&&& 9 3 &&&&&&&&& 9 4 &&&&&&& 2 4 &&&&&&& 2 4 &&&&&&& 2 4 &&&&&&&& 59 '' 3 ''''''''' 9 '' 6 ''''''' 2 '' 6 ''''''' 2 '' 9 ''''''' 35 '' 9 ''''''' 35 '' 9 ''''''' 35 '' 9 '''''' 54 '' net new nurses vs. 2 baseline Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 4,36 Scale- up cost effec+veness rank: 6 Accommoda&on Op&on - Minimum Recommended New residences for new nurse tutors and new students not essen+al given urban se_ng Classroom and Clinical Site Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 2 to Resul+ng es+mated savings: 53, in 25

44 Holy Family College of Nursing Appendix 3 September 2 Summary Increase student intake to 69 in 2, 86 in 23 and 2 in 26 Produc+on increases to 65 in 24, 8 in 26 and 97 in 28 and thereaser Es+mated total scale- up cost (USD): 3,7, Total nurses produced 24-28: 456 Net new nurses produced (vs. baseline): 249 Training Ins&tu&on Profile Located in Phalombe (rural), proprietor- operated (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 7 nurse tutors, 4 clinical instructors and skills lab instructor in 2 Hire 2 tutors in each of 22, 25 and 26 Hire add l clinical instructor in each of 22, 25 and 26 Accommoda&on Build 5- bed hostel in each of 2, 22, 24 and 26 Build tutor house in 22, and 2 in each of 25 and 26 Other Infrastructure Build 3 new classrooms in 2 and in each of 22, 25 and 26 Build new office block in 22 Build new library in 25 Vehicles & Equipment Purchase 4 new vehicles through 26 Purchase 5 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 2,48 Scale- up cost effec+veness rank: 3 Accommoda&on Op&on 3 Full Residen&al Lack of accommoda+on op+ons in rural se_ng, school to provide accommoda+on to all new students and new tutors Classroom and Clinical Site Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 6 to 3 Resul+ng es+mated savings: 59, One- off Costs (USD 's) (USD s) Category Unit Cost Total Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single level library Build/update kitchen/dining facility Buy new computers Transportation # Purchase 32- seat vehicle Accommodation Option - Non Residential # No activities N/A Total One- Time Costs ,29 Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs ,76 Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) ,332 Build new tutor accomm Total One- Time Costs ,726 Recurring Costs (USD 's) Category Unit Cost Total Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended 3,7 249 net new nurses vs. 2 baseline

45 Kamuzu College of Nursing Appendix 3 September 2 Summary Increase student intake to 33 in 2, 44 in 23 and 58 in 26 Prod n increases to 323 in 24, 398 in 26 and 486 in 28 and thereaser Es+mated total scale- up cost (USD): 3,28, Total nurses produced 25-28:,837 Net new nurses produced (vs. baseline): 466 Training Ins&tu&on Profile Located in Lilongwe (urban) operated by University of Malawi (Government) Trains BSC Nurses (Registered), Diploma Nurses (Registered), Registered Midwives (Registered) and Masters in Nursing Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 3 clinical instructors in 2 and 5 in 22 and 23 Hire 5 tutors in 25 Hire 3 clinical instructors in 24, 2 in 25, and in 26 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure Build new classroom in 22, 2 in each of 23 and 24, and in 26 Build new office block in each of 2, 22, 23 and 25 Build single- story library (Blantyre) and mul+- level library (Lilongwe) Vehicles & Equipment Purchase new vehicle in each of 24 and 26 Purchase 7 computers before 26 (38 in 2) Provide textbooks for new and exis+ng students Oneoff'Costs'(USD''s) (USD s) Category 'Unit'Cost' Total Infrastructure # Build&new&classroom &&&&&& 57. &&&&&&& 57 2 &&&&& 4 2 &&&&& 4 3 &&&&& 7 8 &&&&&&&& 456 Build&office&block&(&tutors) &&&&. &&&&& &&&&& &&&&& &&&&& 4 &&&&&&&& 4 Build&single4level&library &&&& 7. &&&&& 7 &&&&&&&& 7 Build&multi4level&library &&&& 24. &&&&& 24 &&&&&&&& 24 Build/update&dining&facilities Buy&new&computers Transportation Purchase&324seat&vehicle &&&& 7. &&&&&&&&. &&&& # &&&&& 7 &&&&&&& 38 7 # &&&&& 7 &&&&&&&&& 7 &&&&& 22 7 # &&&&& 7 &&&&&&&&& 7 &&&&& 22 6 # 2 &&&&& 7 &&&&&&&&& 6 &&&&& # &&&&& 7 &&&&&&&&& 6 9 # 2 &&&&&&&&& 9 &&&&& # 6 &&&&&&&& 535 &&&&&&&&&& 73 &&&&&&&& 732 Accommodation'Option'''Non'Residential # No&activities N/A &&&&&&&&& 4 Total'OneTime'Costs Accommodation'Option'2''Half'Residential # ''''' 26 ''''' 53 ''''' 453 ''''' 687 ''''' 24 ''''' 427 ''''' 2,543 Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& &&&&& 67 &&&&& 663 '',89 2 &&&&& 6 ''''' 69 2 &&&&& 67 &&&&& 6 ''''' &&&&& 67 &&&&& 6 ''''' 96 &&&&& 67 ''''' 38 3 &&&&& 67 &&&&& 33 ''''' &&&&&&&& 833 &&&&&,3 ''''' 4,488 Accommodation'Option'3''Full'Residential # Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& &&&&& 333 &&,325 '',98 4 &&&&& 333 &&&&& 22 '',48 4 &&&&& 333 &&&&& 22 ''''' &&&&& 333 &&&&& 22 '',232 &&&&& 333 ''''' &&&&& 333 &&&&& 265 '', &&&&&,998 &&&&& 2,226 ''''' 6,767 Recurring'Costs'(USD''s) Category Faculty Salary&for&add'l&tutor Salary&for&add'l&skills&lab&instructor Salary&for&add'l&clinical&instructor Total'Recurring'Costs Total'Recommended Unit'Cost Total'(2'' # &&&&&&&& &&&&&&& 28 5 &&&&&&&&&& 28 &&&&&&&& 2.96 &&&&&&&&& 4 &&&&&&&& &&&&&&& &&&&& 4 4 &&&&& 8 44 &&&&& 3 45 &&&&& &&&&& &&&&&&&& 7 3 ' ''''''' ' ''''' 4 4 ' ''''' 8 44 ' ''''' 3 45 ' ''''' 33 5 ' ''''' 65 5 ' '''''''' 739 ' 3,28 Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (25-28): 7,4 Scale- up cost effec+veness rank: 2 Accommoda&on Op&on - Minimum Recommended New residences for new nurse tutors and new students not essen+al given urban se_ng Classroom and Clinical Site Op&miza&on Schedule altered such that pre- service BSCN students commence year in January and other programs commence in July 466 net new nurses vs. 2 baseline

46 Malamulo College of Health Sciences Appendix 3 September 2 Summary Increase student intake to 46 in 2, 57 in 23 and 8 in 26 Produc+on increases to 43 in 24, 54 in 26 and 65 in 28 and thereaser Es+mated total scale- up cost (USD):,55, Total nurses produced 24-28: 34 Net new nurses produced (vs. baseline): 54 Training Ins&tu&on Profile Located in Thyolo (rural) operated by Seventh Day Adven&st (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire skills lab instructor and 3 clinical instructors in 2 Hire 2 nurse tutors in each of 23 and 25 Hire clinical instructor in each of 22, 23 and 25 Accommoda&on Build X student hostels in 2 Build 3 tutor houses in 2 and 2 in each of 22, 23 and 25 Other Infrastructure Build new classroom in each of 2. 22, 23 and 25 Build new office block in 26 Build new library in 26 Vehicles & Equipment Purchase 3 new vehicles through 26 Purchase computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 9,77 Scale- up cost effec+veness rank: 6 Accommoda&on Op&on 3 Full Residen&al Lack of accommoda+on op+ons in rural se_ng, school to provide accommoda+on to all new students and new tutors Classroom and Clinical Site Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 4 to Resul+ng es+mated savings: 59, One- off Costs (USD 's) (USD s) Category Unit Cost Total Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single- level library Build/update dining facilities Buy new computers. 5 5 Transportation # Purchase 32- seat vehicle Accommodation Option - Non Residential # No activities N/A Total One- Time Costs Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs ,83 Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs ,32 Recurring Costs (USD 's) Category Unit Cost Total Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended,55 54 net new nurses vs. 2 baseline

47 MCHS Blantyre Campus Appendix 3 September 2 Summary Increase student intake to 55 in 2, 7 in 23 and 96 in 26 Produc+on increases to 7 in 24, 87 in 26 and 8 in 28 and thereaser Es+mated total scale- up cost (USD): 83, Total nurses produced 24-28: 486 Net new nurses produced (vs. baseline): 62 Training Ins&tu&on Profile Located in Blantyre (urban) operated by University of Malawi (Government) Trains Diploma Nurses (Pre- service and In- service, Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 4 clinical instructors in 2 Hire 2 addi+onal clinical instructors in each of 25 and 26 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure Build new classroom in each of 25 and 26 Build new office block in 22 Build new dining facility in 26 Vehicles & Equipment Purchase new vehicle in each of 22 and 25 Purchase 5 computers before 26 Provide textbooks for new and exis+ng students Oneoff'Costs'(USD''s) (USD s) Category 'Unit'Cost' Total Infrastructure # Build&new&classroom &&&&&& 57. &&&&&&& 57 &&&&&&& 57 2 &&&&&&&& 4 Build&new&skills&lab &&&&&& 67. &&&&&&&&& 4 Build&new&office&block&(&faculty) &&&&. &&&&& &&&&&&&& Build&new&single4level&library &&&& 7. &&&&&&&&& 4 Build/update&dining&facilities &&&& 7. &&&&& 7 &&&&&&&& 7 Buy&new&computers &&&&&&&&. 7 &&&&&&&&& 7 2 &&&&&&&&& 2 &&&&&&&&& &&&&&&&&& 2 &&&&&&&&& 2 &&&&&&&&& 4 &&&&&&&&&& 4 Transportation # Purchase&324seat&vehicle &&&& 22. &&&&& 22 &&&&& 22 &&&&& 22 3 &&&&&&&& 366 Accommodation'Option'''Non'Residential # No&activities N/A &&&&&&&&& 4 Total'OneTime'Costs Accommodation'Option'2''Half'Residential # ''''' 3 ''''' 2 ''''''''' ''''' 24 ''''' 29 ''''''' 58 '''''''' 75 Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& &&&&& 86 ''''' 37 ''''' 2 ''''''''' &&&&&&& 53 ''''' 77 &&&&&&& 53 ''''' 343 &&&&& 67 &&&&&&& 53 ''''' &&&&&&&& 67 &&&&&&&& 345 ''''',26 Accommodation'Option'3''Full'Residential # Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& &&&&& 37 ''''' 52 ''''' 2 ''''''''' 2 &&&&& 6 ''''' 23 2 &&&&& 6 ''''' &&&&& 333 &&&&& 6 ''''' &&&&&&&& 333 &&&&&&&& 689 ''''',727 Recurring'Costs'(USD''s) Category Faculty Salary&for&add'l&tutor Salary&for&add'l&skills&lab&instructor Salary&for&add'l&clinical&instructor Total'Recurring'Costs Total'Recommended Unit'Cost Total # &&&&&&&& 5.68 &&&&&&&&& 4 &&&&&&&& 2.96 &&&&&&&&& 4 &&&&&&&& &&&&&&& 2 4 &&&&&&& 2 4 &&&&&&& 2 5 &&&&&&& 5 8 &&&&&&& 24 8 &&&&&&& 24 8 &&&&&&&&&& 98 ''' 4 ''''''' 2 ''' 4 ''''''' 2 ''' 4 ''''''' 2 ''' 5 ''''''' 5 ''' 8 ''''''' 24 ''' 8 ''''''' 24 ''' 8 '''''''''' 98 '''' 83 Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 2,3 Scale- up cost effec+veness rank: 9 Accommoda&on Op&on - Minimum Recommended New residences for new nurse tutors and new students not essen+al given urban se_ng Classroom and Clinical Site Op&miza&on Schedule altered such that pre- service Diploma Nursing students and upgrading Diploma Nursing students start the year at different +mes 62 net new nurses vs. 2 baseline

48 MCHS Lilongwe Campus Appendix 3 September 2 Summary Increase student intake to 4 in 2, 5 in 23 and 7 in 26 Produc+on increases to 48 in 24, 57 in 26 and 67 in 28 and thereaser Es+mated total scale- up cost (USD): 3, Total nurses trained 24-28: 39 Net new nurses produced (vs. baseline): N/A Training Ins&tu&on Profile Located in Lilongwe (urban) operated by University of Malawi (Government) Trains Community Health Nurse Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 2 clinical instructors in 2 Hire clinical instructor in 22 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure Build new classroom in 22 Build new office block in 22 Vehicles & Equipment Purchase 4 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): N/A Scale- up cost effec+veness rank: N/A Accommoda&on Op&on - Minimum Recommended New residences for new nurse tutors and new students not essen+al given urban se_ng Classroom and Clinical Site Op&miza&on Staggering intake not necessary given sufficient exis+ng classroom space available for scale- up plans Oneoff'Costs'(USD''s) (USD s) Category 'Unit'Cost' Total Infrastructure # Build&new&classroom &&&&&& 57. &&&&&&& 57 &&&&&&&&&& 57 Build&new&skills&lab &&&&&& 67. &&&&&&&&& 4 Build&new&office&block&(&faculty) &&&&. &&&&&&&&& 4 Build&new&single4level&library &&&& 7. &&&&&&&&& 4 Build/update&dining&facility Buy&new&computers Transportation Purchase&324seat&vehicle &&&& 7. &&&&&&&&. # &&&& 22. '' &&&&&&&&& # '' # '' &&&&&&&&& # '' # '' &&&&&&&&& # '' &&&&&&&&& # 4 '' &&&&&&&&& 4 &&&&&&&&&&&& 4 &&&&&&&&& 4 Accommodation'Option'''Non'Residential # No&activities N/A &&&&&&&&& 4 Total'OneTime'Costs Accommodation'Option'2''Half'Residential # ''''''''' 2 ''''''' 58 ''''''''' '''''' ''''''''' ''''''''' '''''''''' 63 Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& 53. &&&&&&& 27 ''''''' 29 &&&&&&& 27 ''''''' 84 ''''''''' '''''' ''''''''' ''''''''' &&&&&&&&& 4 &&&&&&&&&& 53 '''''''' 6 Accommodation'Option'3''Full'Residential # Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& 53. &&&&&&& 53 ''''''' 55 &&&&&&& 53 ''''' ''''''''' '''''' ''''''''' ''''''''' 2 &&&&&&&&& 4 &&&&&&&& 6 '''''''' 69 Recurring'Costs'(USD''s) Category Faculty Salary&for&add'l&tutor Salary&for&add'l&skills&lab&instructor Salary&for&add'l&clinical&instructor Total'Recurring'Costs Total'Recommended Unit'Cost Total # &&&&&&&& 5.68 &&&&&&&&& 4 &&&&&&&& 2.96 &&&&&&&&& 4 &&&&&&&& &&&&&&&&& 6 3 &&&&&&&&& 9 3 &&&&&&&&& 9 3 &&&&&&&&& 9 3 &&&&&&&&& 9 3 &&&&&&&&& 9 3 &&&&&&&&&& 5 ''' 2 ''''''''' 6 ''' 3 ''''''''' 9 ''' 3 ''''''''' 9 ''' 3 ''''''''' 9 ''' 3 ''''''''' 9 ''' 3 ''''''''' 9 ''' 3 '''''''''' 5 '''' 3

49 MCHS Zomba Campus Appendix 3 September 2 Summary Increase student intake to 37 in 2, 7 in 23 and 24 in 26 Prod n increases to 35 in 24, 67 in 26 and 2 in 28 and thereaser Es+mated total scale- up cost (USD): 2,399, Total nurses produced 24-28: 937 Net new nurses produced (vs. baseline): 389 Training Ins&tu&on Profile Located in Zomba (urban) operated by University of Malawi (Government) Trains Nurse Midwife Technicians & Psych Nurse Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 5 tutors in 2, 3 in 22, in 23, 3 in 24 and 2 in 25 and 26 Hire 8 clinical instructors in 2 and in each year 22 to 26 Hire 2 skills lab instructors in 2 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure Build new classroom in each of 23, 24, 25 and 26 Build new office block in each of 2 and 24 Build new library in 24 Build new skills lab in each of 2 and 23 Build new dining facility in 26 Vehicles & Equipment Purchase 8 new vehicles through 26 Purchase 27 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 6,7 Scale- up cost effec+veness rank: Accommoda&on Op&on - Minimum Recommended New residences for new nurse tutors and new students not essen+al given urban se_ng Classroom and Clinical Site Op&miza&on Schedule altered such that pre- service Diploma Nursing students and upgrading Diploma Nursing students start the year at different +mes Oneoff'Costs'(USD''s) Category 'Unit'Cost' (USD Total s) Infrastructure # Build&new&classroom &&&&&& 57. &&&&&&& 57 &&&&&&& 57 &&&&&&& 57 &&&&&&& 57 4 &&&&&&&& 228 Build&new&skills&lab &&&&&& 67. &&&&&&& 67 &&&&&&& 67 2 &&&&&&&& 34 Build&new&office&block&(&faculty) &&&&. &&&&& &&&&& 2 &&&&&&&& 2 Build&new&single4level&library &&&& 7. &&&&& 7 &&&&&&&& 7 Build/update&dining&facilities &&&& 7. &&&&& 7 &&&&&&&& 7 Buy&new&computers &&&&&&&&. 4 &&&&&&& 4 3 &&&&&&&&& 3 2 &&&&&&&&& 2 3 &&&&&&&&& 3 2 &&&&&&&&& 2 3 &&&&&&&&& 3 27 &&&&&&&&&& 27 Transportation # Purchase&324seat&vehicle &&&& &&&&& 6 &&&&& 22 &&&&& 22 &&&&& 22 8 &&&&&&&& 976 Accommodation'Option'''Non'Residential # No&activities N/A &&&&&&&&& 4 Total'OneTime'Costs Accommodation'Option'2''Half'Residential # ''''' 799 ''''''''' 5 ''''' 25 ''''' 39 ''''''' 6 ''''' 29 ''''',796 Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& &&&&& 45 '',249 2 &&&&&&& 8 ''''''' 85 &&&&&&& 27 ''''' &&&&& 333 &&&&&&& 8 ''''' 84 &&&&&&& 53 ''''' 4 &&&&& 333 &&&&&&& 53 ''''' &&&&&&&& 666 &&&&&&&& 742 ''''' 3,24 Accommodation'Option'3''Full'Residential # Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& &&&&& 333 &&&&& 9 '' 2,33 3 &&&&& 333 &&&&& 59 ''''' 497 &&&&& 333 &&&&&&& 53 ''''' &&&&& 333 &&&&& 59 ''''' &&&&& 333 &&&&& 6 ''''' 5 2 &&&&& 333 &&&&& 6 ''''' &&&&&,998 &&&&&,484 ''''' 5,278 Recurring'Costs'(USD''s) Category Faculty Salary&for&add'l&tutor Salary&for&add'l&skills&lab&instructor Salary&for&add'l&clinical&instructor Total'Recurring'Costs Total'Recommended Unit'Cost Total # &&&&&&&& &&&&&&& 28 8 &&&&&&& 45 9 &&&&&&& 5 2 &&&&&&& 68 4 &&&&&&& 8 6 &&&&&&& 9 6 &&&&&&&& 364 &&&&&&&& &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&& 6 3 &&&&&&&&& 9 3 &&&&&&&&& 9 3 &&&&&&&&&& 4 &&&&&&&& &&&&&&& 24 9 &&&&&&& 27 &&&&&&& 33 2 &&&&&&& 36 3 &&&&&&& 38 4 &&&&&&& 4 4 &&&&&&&& 98 5 ' ''''''' 58 9 ' ''''''' ' ''''''' 9 26 ' ''''' 3 ' ''''' ' ''''' 4 33 ' '''''''' 63 ' 2, net new nurses vs. 2 baseline

50 Mulanje Mission College of Nursing Appendix 3 September 2 Summary Increase student intake to 69 in 2, 86 in 23 and 2 in 26 Produc+on increases to 65 in 24, 8 in 26 and 97 in 28 and thereaser Es+mated total scale- up cost (USD):,967, Total nurses produced 24-28: 456 Net new nurses produced (vs. baseline): 239 Training Ins&tu&on Profile Located in Mulanje (peri- urban) operated by CCAP Blantyre Synod (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 2 skills lab instructor and 4 clinical instructors in 2 Hire 2 add l tutors in each of 25 and 26 Hire add l clinical instructor in each of 22, 25 and 26 Accommoda&on Build 25- student hostel in each of 2, 24 and 26 Build 4 tutor houses in 2, and in each of 22, 25 and 26 Other Infrastructure Build 2 new classrooms in 2 and in each of 22, 25 and 26 Build new office block in 22 Vehicles & Equipment Purchase 4 new vehicles through 26 Purchase computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 8,23 Scale- up cost effec+veness rank: 5 Accommoda&on Op&on 2 Half Residen&al Given peri- urban loca+on and thus limited accommoda+on op+ons, TI to provide accommoda+on to half of all new tutors and students Classroom and Clinical Site Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 5 to 2 Resul+ng es+mated savings: 59, in 25 One- off Costs (USD 's) (USD s) Category Unit Cost Total Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single- level library Build/update kitchen/dining facility Buy new computers Transportation # Purchase 32- seat vehicles Accommodation Option - Non Residential # No activities N/A Total One- Time Costs Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs ,83 Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs, ,647 Recurring Costs (USD 's) Category Unit Cost Total Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended, net new nurses vs. 2 baseline

51 Mzuzu University Appendix 3 September 2 Summary Increase student intake to 46 in 2, 57 in 23 and 8 in 26 Produc+on increases to 38 in 24, 49 in 26 and 6 in 28 and thereaser Es+mated total scale- up cost (USD): 8, Total nurses produced 24-28: 228 Net new nurses produced (vs. baseline): 66 Training Ins&tu&on Profile Located in Mzuzu (urban) operated by Mzuzu University (Government) Trains BSC Nurses (registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 7 clinical instructors in 2 and in each of 22 and 23 Hire tutor in 26 Hire add l clinical instructor in each of 24 and 26 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure Build new classroom in 26 Build new office block in 22 Build new library in 23 Build new dining facility in 26 Vehicles & Equipment Purchase 3 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Oneoff'Costs'(USD''s) Category 'Unit'Cost' (USD s) Total Infrastructure # Build&new&classroom &&&&&& 57. &&&&&&& 57 &&&&&&&&&& 57 Build&new&skills&lab &&&&&& 67. &&&&&&&&& 4 Build&new&office&block&(&faculty) &&&&. &&&&& &&&&&&&& Build&new&multi4level&library &&&& 24. &&&&& 24 &&&&&&&& 24 Build/update&dining&facilities &&&& 7. &&&&& 7 &&&&&&&& 7 Buy&new&computers &&&&&&&&. 7 &&&&&&&&& 7 &&&&&&&&& &&&&&&&&& &&&&&&&&& &&&&&&&&& 2 &&&&&&&&& 2 3 &&&&&&&&&& 3 Transportation # Purchase&324seat&vehicle &&&& 22. &&&&& 22 &&&&&&&& 22 Accommodation'Option'''Non'Residential # No&activities N/A &&&&&&&&& 4 Total'OneTime'Costs Accommodation'Option'2''Half'Residential # ''''''' ''''' 2 ''''' 338 ''''''''' 2 ''''''''' ''''' 68 '''''''' 62 Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& &&&&& 67 &&&&& 86 ''''' 363 &&&&&&& 27 ''''' 28 &&&&& 67 &&&&&&& 53 ''''' 557 &&&&& 67 &&&&&&& 53 ''''' 222 ''''''''' &&&&& 67 &&&&&&& 27 ''''' &&&&&&&& 666 &&&&&&&& 345 ''''',63 Accommodation'Option'3''Full'Residential # Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& &&&&& 333 &&&&& 37 ''''' 75 &&&&& 333 &&&&&&& 53 ''''' &&&&& 333 &&&&& 6 ''''' &&&&& 333 &&&&& 6 ''''' 44 ''''''''' &&&&& 333 &&&&&&& 53 ''''' &&&&&,665 &&&&&&&& 689 ''''' 2,974 Recurring'Costs'(USD''s) Category Faculty Salary&for&add'l&tutor Salary&for&add'l&skills&lab&instructor Salary&for&add'l&clinical&instructor Total'Recurring'Costs Total'Recommended Unit'Cost Total # &&&&&&&& 5.68 &&&&&&&&& 6 &&&&&&&&&&&& 6 &&&&&&&& 2.96 &&&&&&&&& 4 &&&&&&&& &&&&&&& 2 8 &&&&&&& 24 9 &&&&&&& 27 &&&&&&& 33 &&&&&&& 33 3 &&&&&&& 38 3 &&&&&&&& 75 ''' 7 ''''''' 2 ''' 8 ''''''' 24 ''' 9 ''''''' 27 ' ''''''' 33 ' ''''''' 33 4 ' ''''''' 44 4 ' '''''''' 8 '''' 8 66 net new nurses vs. 2 baseline Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28):,56 Scale- up cost effec+veness rank: 8 Accommoda&on Op&on - Minimum Recommended New residences for new nurse tutors and new students not essen+al given urban se_ng Schedule Op&miza&on Staggered intake not necessary as addi+onal classroom requirements to absorb scale- up are insignificant

52 Nkhoma College of Nursing Appendix 3 September 2 Summary Increase student intake to 69 in 2, 86 in 23 and 2 in 26 Produc+on increases to 65 in 24, 8 in 26 and 97 in 28 and thereaser Es+mated total scale- up cost (USD): 2,96, Total nurses produced 24-28: 456 Net new nurses produced (vs. baseline): 99 Training Ins&tu&on Profile Located in Nkhoma (rural) operated by Nkhoma CCAP Synod (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 5 tutors in 2 and 2 add l tutor in each of 22, 25 and 26 Hire add l skills lab instructor in 2 Hire 5 clinical instructors in 2 and add l in 22, 25 and 26 Accommoda&on Build 5- bed hostel in each of 2, 22, 24 and 26 Build tutor house in 22 and 2 in each of 25 and 26 Other Infrastructure Build 3 classrooms in 2 and add l in each of 22, 25 and 26 Build new office block in 22 Vehicles & Equipment Purchase 2 vehicles in 2 and vehicle in 25 Purchase 4 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 4,6 Scale- up cost effec+veness rank: 2 Accommoda&on Op&on 3 Full Residen&al Lack of accommoda+on op+ons in rural se_ng, school to provide accommoda+on to all new students and new tutors Schedule Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 6 to 3 Resul+ng es+mated savings: 59, One- off Costs (USD 's) Category Unit Cost (USD Total s) Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single- level library Build/update dining facilities Buy new computers Transportation # Purchase 32- seat vehicle Accommodation Option - Non Residential # No activities N/A Total One- Time Costs Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs ,532 Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) ,332 Build new tutor accomm Total One- Time Costs ,497 Recurring Costs (USD 's) Category Unit Cost Total Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended 2,96 99 net new nurses vs. 2 baseline

53 St. John of God College of Nursing Appendix 3 September 2 Summary Increase student intake to 23 in 2, 29 in 23 and 4 in 26 Produc+on increases to 24 in 24, 3 in 26 and 38 in 28 and thereaser Es+mated total scale- up cost (USD): 49, Total nurses produced 24-28: 66 Net new nurses produced (vs. baseline): N/A Training Ins&tu&on Profile Located in Mzuzu (urban) operated by SJOG Community Services (CHAM) Trains Psychiatric Nurses (Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire clinical instructors in 2 and in 24 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure No addi+onal infrastructure necessary Vehicles & Equipment Purchase 3 computers before 26 Provide textbooks for new and exis+ng students One- off Costs (USD 's) (USD s) Category Unit Cost Total Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single- level library Build/update dining facilities Buy new computers Transportation # Purchase 32- seat vehicles Accommodation Option - Non Residential # No activities N/A Total One- Time Costs Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs Recurring Costs (USD 's) Category Unit Cost Total (2 - Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended 49 Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): N/A Scale- up cost effec+veness rank: N/A Accommoda&on Op&on - Minimum Recommended New residences for new nurse tutors and new students not essen+al given urban se_ng Schedule Op&miza&on Staggering intake not necessary given no addi+onal classroom requirements to absorb addi+onal student intake

54 St. John s College of Nursing Appendix 3 September 2 Summary Increase student intake to 57 in 2, 7 in 23 and in 26 Produc+on increases to 54 in 24, 67 in 26 and 8 in 28 and thereaser Es+mated total scale- up cost (USD):,68, Total nurses produced 24-28: 38 Net new nurses produced (vs. baseline): 2 Training Ins&tu&on Profile Located in Mzuzu (urban) operated by Bishop Zuza (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire tutors in 2 and 2 tutors in each of 22 and 23 Hire skills lab instructor in 2 and 22 Hire 2 clinical instructors in 2 and in each of 22 and 23 Accommoda&on Under minimum recommended guideline, build no new accommoda+on Other Infrastructure Build 3 new classroom in 2 and in each of 22 and 23 Build office block in 22 and 25 Build new library in 23 Vehicles & Equipment Purchase 2 vehicles in 2 and vehicle in 23 Purchase 2 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Oneoff'Costs'(USD''s) (USD s) Category 'Unit'Cost' Total Infrastructure # Build&new&classroom &&&&&& &&&&& 228 &&&&&&& 57 &&&&&&& 57 6 &&&&&&&& 342 Build&new&skills&lab &&&&&& 67. &&&&&&& 67 &&&&&&& 67 2 &&&&&&&& 34 Build&new&office&block&(&faculty) &&&&. &&&&& &&&&& 2 &&&&&&&& 2 Build&new&multi9level&library &&&& 24. &&&&& 24 &&&&&&&& 24 Build/update&dining&facilities Buy&new&computers Transportation Purchase&329sesat&vehicle &&&& 7. &&&&&&&&. &&&& 22. # 2 &&&&& 244 # &&&&& 22 # &&&&& 22 # # # # 4 &&&&&&&&& 9 &&&&&&&&& 9 &&&&&&&& 488 Accommodation'Option'''Non'Residential # No&activities N/A &&&&&&&&& 9 Total'OneTime'Costs Accommodation'Option'2''Half'Residential # ''''' 542 ''''' 28 ''''' 394 ''''''' 69 ''''' ''''''''' 2 ''''',386 Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& 53. ''''' 542 ''''' 28 ''''' 394 ''''''' 69 &&&&& 67 ''''' 267 ''''''''' 2 &&&&&&&& 67 &&&&&&&&& 9 ''''',553 Accommodation'Option'3''Full'Residential # Build&new&student&accomm.&(5&beds) Build&new&tutor&accomm. Total'OneTime'Costs &&&& 333. &&&&&& 53. ''''' 542 &&&&& 333 ''''' 63 ''''' 394 ''''''' 69 &&&&& 333 ''''' 433 ''''''''' 2 2 &&&&&&&& 666 &&&&&&&&& 9 ''''' 2,52 Recurring'Costs'(USD''s) Category Faculty Salary&for&add'l&tutor Salary&for&add'l&skills&lab&instructor Salary&for&add'l&clinical&instructor Total'Recurring'Costs Total'Recommended Unit'Cost Total # &&&&&&&& 5.68 &&&&&&&&& 6 3 &&&&&&& 7 3 &&&&&&& 7 5 &&&&&&& 28 5 &&&&&&&&&& 68 &&&&&&&& &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&& 6 2 &&&&&&&&&& 36 &&&&&&&& &&&&&&& 2 5 &&&&&&& 5 6 &&&&&&& 8 8 &&&&&&& 24 8 &&&&&&& 24 9 &&&&&&& 27 9 &&&&&&&& 8 ''' 6 ''''''' 8 ''' 7 ''''''' 2 ''' 9 ''''''' 29 3 ' ''''''' 47 3 ' ''''''' 47 6 ' ''''''' 6 6 ' '''''''' 222 ',68 2 net new nurses vs. 2 baseline Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 5,77 Scale- up cost effec+veness rank: 4 Accommoda&on Op&on - Minimum Recommended New residences for new nurse tutors and new students not essen+al given urban se_ng Schedule Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 6 to 4 Resul+ng es+mated savings: 6,

55 St. Joseph s College of Nursing Appendix 3 September 2 Summary Increase student intake to 97 in 2, 2 in 23 and 7 in 26 Prod n increases to 92 in 24, 5 in 26 and 37 in 28 and thereaser Es+mated total scale- up cost (USD): 2,678, Total nurses produced 24-28: 647 Net new nurses produced (vs. baseline): 38 Training Ins&tu&on Profile Located in Chiradzulu (peri- urban) operated by Archdiocese Blantyre (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 2 skills lab instructors and 4 clinical instructors in 2 Hire tutor in 23 and 2 in each of 24 and 26 Hire add l clinical instructor in each of 22, 23 and 26 and 2 in 24 Accommoda&on Build 5- bed student hostel in each of 2 and 23 Build 4 tutors houses in 2, in each of 22, 23, 24 and 26 Other Infrastructure Build 4 new classrooms in 2 and in each of 22 and 23 Build office block in 22 and 24 and dining hall in 26 Build new library in 2 and 24 Vehicles & Equipment Purchase 3 vehicles through 26 Purchase 22 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 8,69 Scale- up cost effec+veness rank: 7 Accommoda&on Op&on 2 Half Residen&al Given limited accommoda+on op+ons, TI should provide accommoda+on for half of all new students and new tutors Schedule Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 6 to 3 Resul+ng es+mated savings: 59, One- off Costs (USD 's) (USD s) Category Unit Cost Total Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single- level library Build/update dining facilities Buy new computers Transportation # Purchase 32- seat vehicles Accommodation Option - Non Residential # No activities N/A Total One- Time Costs ,392 Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs, ,456 Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) ,332 Build new tutor accomm Total One- Time Costs, ,59 Recurring Costs (USD 's) Category Unit Cost Total Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended 2, net new nurses vs. 2 baseline

56 St. Luke s College of Nursing Appendix 3 September 2 Summary Increase student intake to 69 in 2, 86 in 23 and 2 in 26 Produc+on increases to 65 in 24, 8 in 26 and 97 in 28 and thereaser Es+mated total scale- up cost (USD):,869, Total nurses produced 24-28: 456 Net new nurses produced (vs. baseline): 59 Training Ins&tu&on Profile Located in Zomba (peri- urban), proprietor- operated (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 3 tutors, 2 skills lab instructors and 5 clinical instructors in 2 Hire 2 add l clinical instructors in each of 22, 25 and 26 Hire add l clinical instructor in each of 22, 25 and 26 Accommoda&on Build 25- bed student hostel in each of 2 and 23 Build tutor house in 2 and 2 in each of 22, 25 and 26 Other Infrastructure Build 2 classrooms in 2 and in each of 22, 25 and 26 Build new office block in 22 Build new skills lab in 2 Vehicles & Equipment Purchase 2 vehicles in 2 and in 25 Purchase 5 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons One- off Costs (USD 's) (USD s) Category Unit Cost Total Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single- level library Build/update dining facilities Buy new computers Transportation # Purchase 32- seat vehicles Accommodation Option - Non Residential # No activities N/A Total One- Time Costs Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs ,528 Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs ,23 Recurring Costs (USD 's) Category Unit Cost Total Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended, net new nurses vs. 2 baseline Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28):,75 Scale- up cost effec+veness rank: Accommoda&on Op&on 2 Half Residen&al Given limited accommoda+on op+ons, TI to provide accommoda+on for half of all new students and new tutors Schedule Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 5 to 2 Resul+ng es+mated savings: 59, in 25

57 Trinity College of Nursing Appendix 3 September 2 Summary Increase student intake to 69 in 2, 86 in 23 and 2 in 26 Produc+on increases to 65 in 24, 8 in 26 and 97 in 28 and thereaser Es+mated total scale- up cost (USD): 2,979, Total nurses produced 24-28: 456 Net new nurses produced (vs. baseline): 24 Training Ins&tu&on Profile Located in Nsanje (rural), proprietor- operated (CHAM) Trains Nurse Midwife Technicians (non- Registered) Key Ac&vi&es to Achieve Scale- up Targets Faculty Hire 5 tutors, 2 skills lab instructors and 6 clinical instructors in 2 Hire 2 add l tutors In each of 22, 25 and 26 Hire add l clinical instructor in each of 22, 25 and 26 Accommoda&on Build 5- bed student hostel in each of 2, 23 and 25 Build 4 tutor houses in 2 and 2 in each of 22, 25 and 26 Other Infrastructure Build 3 new classrooms in 2, and in each of 22, 25 and 26 Build new skills lab in 2 Build new office block in 22 Vehicles & Equipment Purchase 4 vehicles through 26 Purchase 5 computers before 26 Provide textbooks for new and exis+ng students Addi&onal Considera&ons One- off Costs (USD 's) (USD s) Category Unit Cost Total Infrastructure # Build new classroom Build new skills lab Build new office block ( faculty) Build new single- level library Build/update dining facilities Buy new computers Transportation # Purchase 32- seat vehicles Accommodation Option - Non Residential # No activities N/A Total One- Time Costs ,23 Accommodation Option 2 - Half Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs ,788 Accommodation Option 3 - Full Residential # Build new student accomm. (5 beds) Build new tutor accomm Total One- Time Costs, ,552 Recurring Costs (USD 's) Category Unit Cost Total Faculty # Salary for add'l tutor Salary for add'l skills lab instructor Salary for add'l clinical instructor Total Recurring Costs Total Recommended 2, net new nurses vs. 2 baseline Scale- up Cost Effec&veness Es+mated scale- up cost per net new graduate (24-28): 4,6 Scale- up cost effec+veness rank: Accommoda&on Op&on 3 Full Residen&al Given lack of accommoda+on op+ons in area, TI to provide accommoda+on to all new students and new tutors Schedule Op&miza&on Staggering intake using NMCM approved NMT Academic Calendar reduces classrooms to construct from 6 to 3 Resul+ng es+mated savings: 59,

58 Esmated Student Fees Appendix 3 September 2 Based on expected student enrollment, and estimated student fees, the following table shows the estimated total student fees in USD per training institution above the scale-up costs set out in the training operational plans. School Ekwendeni(Nursing(College Holy(Family(Nursing(College Kamuzu(College(of(Nursing Malamulo(College(of(Health(Sciences MCHS(>(Blantyre MCHS(>(Lilongwe Dae(Yang(College(of(Nursing MCHS(>(Zomba Mulanje(Mission(School Mzuzu(University Nkhoma(College(of(Nursing St(John(of(God St(Johns(Nursing(College St(Josephs(Nursing(College St(Lukes(College(of(Nursing Trinity(College(of(Nursing All'Programs Est.'Fees/student Estimated'Total'Student'Fees'(USD) MWK USD Total ((((((( 335, ((((((((((( 2,3 ((((((( 278,52 ((((((( 36,576 ((((((( 345,52 ((((((( 38,697 ((((((( 42,273 ((((((( 47,3 (((( 2,22,879 ((((((( 335, ((((((((((( 2,3 ((((((( 8,697 ((((((( 332,97 ((((((( 458,848 ((((((( 59,66 ((((((( 56,364 ((((((( 629,394 (((( 2,67,879 ((((((( 85, ((((((((((( 5,52 (((( 3,997,576 (((( 4,64,55 (((( 5,424,545 (((( 6,32,424 (((( 6,666,6 (((( 7,52,22 (( 34,283,333 ((((((( 335, ((((((((((( 2,3 ((((((( 229,424 ((((((( 274,9 ((((((( 36,576 ((((((( 339,6 ((((((( 373,576 ((((((( 42,273 ((((,943, ((((((( 335, ((((((((((( 2,3 ((((((( 322,88 ((((((( 375,66 ((((((( 426,364 ((((((( 48,82 ((((((( 533,97 ((((((( 69,9 (((( 2,749,3 ((((((( 335, ((((((((((( 2,3 ((((((((( 95,424 ((((((( 7,758 ((((((( 42,2 ((((((( 64,455 ((((((( 88,88 ((((((( 235,55 ((((((( 944,9 ((((((( 335, ((((((((((( 2,3 ((((((( 3,697 ((((((( 29,939 ((((((( 44,52 ((((((( 6,394 ((((((( 76,636 ((((((( 98,97 ((((((( 923,788 ((((((( 335, ((((((((((( 2,3 ((((((( 62,273 ((((((( 734,97 ((((((( 822,273 ((((((( 93,636 ((((,5, ((((,28,848 (((( 5,226, ((((((( 335, ((((((((((( 2,3 ((((((( 345,52 ((((((( 4,2 ((((((( 458,848 ((((((( 59,66 ((((((( 56,364 ((((((( 629,394 (((( 2,93,485 ((((((( 3, (((((((((((,88 ((((((( 287,273 ((((((( 32,727 ((((((( 347,273 ((((((( 387,273 ((((((( 429,9 ((((((( 48, (((( 2,243,636 ((((((( 335, ((((((((((( 2,3 ((((((( 345,52 ((((((( 4,2 ((((((( 458,848 ((((((( 59,66 ((((((( 56,364 ((((((( 629,394 (((( 2,93,485 ((((((( 55, ((((((((((( 3,333 ((((((( 4, ((((((( 6, ((((((( 8, ((((((( 96,667 ((((((( 26,667 ((((((( 243,333 ((((,36,667 ((((((( 335, ((((((((((( 2,3 ((((((( 229,424 ((((((( 34,9 ((((((( 38,697 ((((((( 424,333 ((((((( 466,97 ((((((( 523,88 (((( 2,367,333 ((((((( 335, ((((((((((( 2,3 ((((((( 489,33 ((((((( 58,667 ((((((( 649,697 ((((((( 722,788 ((((((( 793,848 ((((((( 89,33 (((( 4,27,66 ((((((( 335, ((((((((((( 2,3 ((((((( 345,52 ((((((( 4,2 ((((((( 458,848 ((((((( 59,66 ((((((( 56,364 ((((((( 629,394 (((( 2,93,485 ((((((( 335, ((((((((((( 2,3 ((((((( 345,52 ((((((( 4,2 ((((((( 458,848 ((((((( 59,66 ((((((( 56,364 ((((((( 629,394 (((( 2,93,485 '''' 8,365,667 '''' 9,948,394 ',464,9 ' 2,75,939 ' 4,72,727 ' 5,87,364 ' 72,473,82