Malawi's health care is delivered through three levels of the government system: Central referral hospitals (located in major cities), district hospitals, and rural health clinics. Though free, the facilities are extremely under-resourced. There is a grave shortage of health care personnel, and one nurse commonly cares for 50 or more hospitalized patients. Many district hospitals have only one, or sometimes no physician, with medical care provided by clinical officers (with training similar to physician's assistants in the US).

The Malawi health care system has been presented in the US press (Dugger, 2004) as an example of the "brain drain" of professionally trained health care personnel. Attractive pay and notably better workplace conditions have drawn some of the best African health professionals, including nurses, to northern hemisphere countries. Great Britain's Department for International Development (DFID) has recently begun ameliorating the brain drain by "topping off" nurses' salaries. Even so, the internal brain drain from the public hospital and clinic system remains a problem as Malawi nurses seek more lucrative work in non-governmental organizations (Gorman, 2009).

Exacerbating the problem is the loss of nurses to the HIV and AIDS epidemic, and the lack of upward mobility and of continuing education in the public system (Manafa, et al, 2009). At the same time, replenishing the work force is challenging. Though the cost of nursing education is modest by U.S. standards, it is far beyond the reach of many qualified Malawi people. All these factors make Malawi's health care worker shortage particularly acute, even when compared with the rest of sub-Saharan Africa. The country has only 29 nurses for every 100,000 people, contrasted with 85 in Tanzania, 472 in South

Africa, and 836 in the U.S (WHO, 2005; Kaiser Family Foundation, 2008).

The purpose of this project is to partner with the Government of Malawi, Kamuzu College of Nursing, and the University of California, San Francisco, to: 1) increase the Malawi nursing workforce, and 2) build long-term sustainability of HIV and AIDS programs and delivery of primary health care to women.

This program will build on Global AIDS Interfaith Alliance's (GAIA's) already successful Nursing Scholarship Program, and at the end of five years will result in approximately 130 new Malawi registered nurses, who have been trained in Malawi and are committed to a service obligation of at least three years (four for those receiving a bachelors degree) in Malawi government and Christian Health Association of Malawi (CHAM) hospitals.

Further, the project will build HIV and AIDS and women's health programs through addressing and strengthening three key areas: 1) antiretroviral therapy (ART), 2) basic emergency obstetrical care (BEmOC), and 3) triage. The capacity of schools of nursing to deliver these skills to students and to practicing nurses in the field will be enhanced.

The purpose of the proposed project is thus consonant with Goal IV, Cross Cutting Systems Strengthening, as outlined in the President's Emergency Plan for AIDS Relief (PEPFAR) Partnership Framework Document to Support Implementation of the Malawi National HIV and AIDS Response between the Government of the United States of America and the Government of the Republic of Malawi (May 2009)

The proposed project is a Systems Strengthening strategy that improves health services. Systems Strengthening means increasing the number and boosting the skills of health and social welfare workers graduating from pre-service training institutions and, importantly, the number being retained in the Malawi health and social welfare workforce. In particular, the program would contribute approximately 130 newly graduated health workers towards the human resources target indicator of 1000 defined in the Malawi PEPFAR Partnership Framework document under Goal IV. Moreover, extrapolating from a recent Malawi Health Sector Employee Census data (GOM, 2007), we estimate that the 130 graduates would fill approximately 8% of the nursing vacancies in the health workforce and would therefore make a substantive contribution toward the desired Malawi PEPFAR Framework Document goal of filling 50% of the vacancies in the health and social welfare workforce.

While Goal IV of the Framework represents the primary fit with the proposed project, two other goals will also be supported, because increasing the number of nursing workforce while strengthening their skills will contribute to reduced HIV infections in Malawi (Goal I), and improve the quality of treatment and care

for Malawians living with HIV (Goal II).

The project will improve access to BEmOC through a train-the-trainer model that will build workforce BEmOC capability (see budget code narrative, below).

Budget Summary

PFIP Year 1 Funding - $213,002 PFIP Year 2 Funding - $100,000