Monday, 25 February 2008

Primary Health workers: Is Quantity better than Quality in Malawi?

Am no politician, but Health is politics, and if you are interested in health issues in Malawi then follow discussions and debate below.
How often do researchers aim to publish findings from our findings from studies in Malawi in top journals /magazines like the “New York times” ,“British Medical journal” ,"The economists” and many others ? Well not many Malawians have access to such papers and may not even read about issues affecting them.
This is why I am publishing our preliminary research results on this blog, hoping that a few people interested in Malawi will read the whole article.

I am trying to design methods/ways of how primary health care workers can be used to find blind and visual impaired children in the villages early and bring them to our hospital for surgical intervention .Health surveillance assistants (HSA) are the lowest cadre of health workers in Malawi and most of their work involves working in a community surrounding a Health Centre .In 2007 there were about 6,000 HSA’s in the whole country (1 per 2,000 population).Within the last 3 months the Ministry of Health through a grant from Global Fight for TB , HIV, and Malaria have almost doubled the number of HSA by employing another ?6000 (no one knows exactly how many more but this number is supposed to have been achieved) on a temporary basis.

Is it a matter of increasing the numbers or improving the quality of performance of the existing ones? To answer this question lets discuss what HSA’s do in the health system in Malawi?

HSA’s are the first level of contact with the patients in the community and they are supposed to give health promotion (HSA were first recruited in Malawi for Cholera prevention programmes), but unfortunately currently they do a lot; give immunisations to children, treat fever in children, treat pneumonia, malaria, supervise patients on TB and ARV, give support to home based care, implement NGO’s programmes and many other duties. Talks about them whether being qualified to give ARV’s have been debated with no consensus reached.
HSA’s only undergo a 3 month short training medical course and currently they need to have a certificate (MSCE/JCE) to be accepted for the course. After graduation they become experts on every disease in the community and are supposed to offer primary health care (first level care) and then refer difficulty cases.

Well my Research Team last month (January) conducted Focus Group discussions (FGD) in 3 districts in Southern Malawi interviewing 30 HSA’s on what they know and do about eye diseases .We started in Mulanje (Chisitu and Chonde health centres), and then went to Mangochi (Chilipa and Nkope and Namwera Health centre, 40mKm from Mangochi Boma,), and finished in Chirazulu (Monfort /Nguludi Health Centres).

What did we find?
Almost half of the HSA’s at health centres were new having been employed with the last 3 months. They had not attended any form of training and they did not know when they would go for the 3 months course. Most of the old HSA’s had been trained, however surprisingly some of the HSA had not been formally trained 2 years after they started they job (work was all learned on the job).
Concerning Eye care both the old and the new HSA did not know the causes of eye diseases and how to treat or prevent them .The trained ones indicated that the 3 months course did not cover any eye diseases. There was no difference in the level of knowledge of eye diseases between the trained and untrained ones .Asked what they do when they see eye patients in the community, most of them just gave any eye drops available.
More than 50% of HSA’s believed that traditional herbal medicine can be used to treat eye conditions, and reported knowing either a relative or themselves using herbal medicine .The herbs used mainly in form of powder or eye drops included pepper leaves, green tomato leaves, fresh urine from patient and mothers expressed breast milk. Two HSA had personally used these herbs for treating their own eyes.

All HSA’s admitted to seriously needing some form of training in primary eye care and plans are underway to train some of them hopefully starting by June.

We did not deeply access the HSA’s knowledge and performance on other diseases.

The numbers of HSA has indeed drastically increased in Malawi but their quality of performance in eyes diseases is very poor.
Massive training and evaluation programmes are needed to assess future impact of HSA on eye diseases and further research is needed to assess their knowledge and performance in other diseases.

Research funds provided by International Centre for Eye Health London

What do you say?
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Saturday, 23 February 2008

? The cursed position of “Director of Clinical services” in the Ministry of Health in Malawi

The Director of Clinical services at the Ministry of Health Headquarters is responsible for directing all services relating to clinical matters in all the Government Hospitals in Malawi .This is a very high position in the Ministry and the person heading the post is responsible (among many other things) for posting of Specialist Doctors, General doctors Clinical officers, medical offers and other paramedical clinical staff in various hospitals in Malawi. Most importantly this is the person who acts as a technical advisor to the Principal Secretary (PS) and sometimes directly to the Minister.
The appointment of a person to this position is political and no interviews are conducting whenever a vacancy exists. However the post is that of a top civil servant (Contract position –almost equivalent to PS ) and I do not know who appoints the officer but anecdotal evidence suggests that it is t the Health PS in position who suggest the suitable name to the Secretary of President and cabinet .
In a system where ministers of Health and PS’s are frequently changed one would expect the Director of clinical services to be the gate keeper of ministry of Health and remain in that vital position for a while.
In my 12 years of working in the ministry of Health I have noted that this position is one of the most cursed position in the Ministry; and that when one is nominated to take up the post; they should be preparing to leave the post anytime regardless of their performance (for once I do not know how they are assessed and who assesses them).
Just within the last 12 years there have been 7 Directors of Clinical Services (of whom 6 have been doctors and one a clinical officer).

The table below summarises terms served by the persons involved
Year, Directors names, What happened and where now?
1996-1998 Dr W Chaziya Removed & Practising outside Malawi
1998-1999 Dr R Pendame Promoted to PS and later removed; working outside Malawi
2001-2004 Dr R Mpazanje Removed and working outside Malawi
2004-2005 Mr Mthotha Demoted in 2005;working outside Malawi
2005-2006 Dr D Lungu Removed ;sent to work as a specialist in a hospital in Malawi
2006-2007 Mr Mthotha Promoted and sent outside Malawi as medical attaché
2007- Dr MC Joshua Demoted ;sent back to district hospital
2007-2008 Dr GC Mwale Currently in position

It is worth noting that once these top civil servants have been removed from the position of Director of clinical services; they normally get jobs outside Malawi.

But the question remains; with such a rapid turnover are these people able to grasp and act on the Ministry of Health needs? I don’t think so. By the time they start understanding the politics of the ministry and are ready to start implementing their plans then they are replaced.
Are wrong people being selected? Considering that this is such an important position should there be interviews to select people with appropriate credentials?

Next time the vacancy of Director of Clinical services exists at the Ministry of Health in Malawi, don’t suggest my name- because this position is cursed and one can not last no matter how good they claim to be.

Do you believe in Curses? I don’t!!

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Wednesday, 20 February 2008

I am now Honorable Dr KK- Minister -Guess why!!

A few weeks ago I got a text message on a Saturday morning while in Johannesburg South Africa, that I had been elected minister of Health in Malawi and that the ceremony was going to be on the coming Monday and that if possible I needed to get back home .I was in transit on my way to India to attend the 66th annual conference for Eye specialists .The reaction to the message was with mixed feeling; firstly why did the big boss not communicate to me /or tip me before electing me; and that if this was true then what would happen to my community job as an eye specialist.
I looked at the reasons why possibly I could have been considered for the post and they looked to be many; I have worked in the ministry of Health and have over 12 years experience as doctor; am a specialist Dr ,and possibly I am rightly qualified. Factors against me being elected were that I am non political, non partisans and stick to my profession ethics and have difficulties in following beaucratic ministerial procedures. Overall I considered it was going to be a good opportunity for me to be a health minister; the six figure salary, the Mercedes Benz with the personal driver, the games played in parliament and overall the lack of seriousness in working (just following orders from above) –and of course I could do the job better than other people who have been there before and it would be a good break for me to leave my dirty work in the community with poor blind people. I thanked the one (whoever it was) who had suggested my name to him who appoints. Yes I was ready to cancel my flight and get back to Blantyre Malawi and this time on a business class ticket. Well after many years of hard work my life seemed to have been transformed overnight.
I needed to verify this information before cancelling the ticket so I had to call Malawi; obviously my wife being also non political and rarely listening to Malawi news may or may not have heard this good news so I decided to call my boss (who was now my subordinate and would call me sir/honourable) and his reaction was laughter. He said I had almost made it to the Cabinet, by magic and by logical deduction. You see two people were elected as ministers of Health; the real minister and his deputy. The chosen minister’s first name was Khumbo but his surname was not “Kalua”. And imagine the deputy minister’s surname was Kalua but his first name was not Khumbo. So during the cabinet announcement people heard names of Khumbo and Kalua under the ministry of Health and it was right to conclude that it was me (but do I deserve the post?). For a brief moment I enjoyed the status of being a minister and a politician but I remain a “popper” as of today. I wonder why the big man had to tease me that way. Please don’t call me honourable next time we meet. I continue serving people who suffer from eye diseases from the rural communities of Malawi.
What do you think?
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Fate of a Malawian in Snowing Glasgow, Scotland

I have just been in Glasgow Scotland for a few days now but the weather has been horrible making it impossible for me to have a good time and take nice photos .As a freelance medical journalist I like recording and reporting about where I am in this part of the world. This February 2008 I have moved from India to Scotland on my way to Blantyre Malawi .In Scotland I am visiting the York hill Childrens Hospital in Glasgow and I am staying at Campanile Hotel. The hospital is very nice and staff are very friendly. Tonight I have been invited for dinner. Most of the staff at York hill have also visited our hospital in Blantyre.
I have not had much time to see the town; partly because it’s been extremely cold (temperatures below -4 degrees) and snowing making it impossible to travel; especially for a local Malawian who is used to the warm heart of Malawi weather. I still have a few more days in Glasgow so hopefully I should manage to take nice photos. And I will write more of the experiences then.

Friday, 8 February 2008

From India to Malawi via Scotland

I love travelling; and its one thing I never get tired of. Indeed if I was awaken up in the middle of the night and asked what my hobbies are, travelling would still come first. That’s why I love working in the rural communities of Malawi as this gives me endless opportunity to see different places in Malawi. But I also enjoy seeing places outside Malawi (anyway who doesn’t?) and my job seems to offer the best solution for my passion; that’s mixing business with pleasure.
This is why after working so hard in India for the last few days I have decided that on my way to Blantyre, Malawi I have Stop in Scotland, pariculary to visit Glasgow. Scotland in one the four Islands that form the United Kingdom and Scotland has two main cities; Edinburgh and Glasgow. I last visited Edinburgh in December 2004; we were on holiday with my family and we stayed at a bed and breakfast hotel. Unfortunately at that time the weather was so bad (it was winter season and it was snowing heavily) such that we did not get out of our rooms to see the city. We only managed to see the castle and then go to the Cinema.
This time I am on business visiting the York hill children’s Hospital (Spending some time in Eye department) .The hospital in Blantyre, Malawi (where I work) and the York hill Hospital are twins (the birth year of the Link was in 2006) and so it is nature that I have decided to visit our brothers and sister there and pass warm greetings from Malawi. And since the weather is not bad (winter is over and spring is coming) I may actually be seeing interesting places. Keep fingers closed; I should be posting pictures on Glasgow on this blog soon. I am excited and yes I love my Job.

Thursday, 7 February 2008

Blogging from India

After spending Christmas in a remote area, I decided to Visit India for a change and have my birthday there. Yes I have added another year.
India has a lot of exciting things to offer. It is a nation for the rich and the poor; with the gap widening more.
Surprisingly one does not see many people of African origin; infact I am the only one here.
And I have started liking Indian dishes (doesn’t have a choice).
I am attending a conference of the Indian eye specialists-there are a total of about 10,000 eye specialist in India (contrast with the half a dozen we still have in Malawi) .
I do not have much access to internet; so I will leave the rest for when I am out of here. But I have managed to have some nice photos.
I have become too busy as of late that I have decided I will have to stop Blogging completely.
Greetings from India.