Task sharing within a managed clinical network to improve child health in Malawi

The health system in Malawi

Malawi has a rapidly growing population of currently 16 million, 80% of whom live
in rural areas and approximately 50% of whom are less than 15 years old; the paediatrician-to-child
ratio is 1:500 000. However, the country has an extensive tiered health system infrastructure
based on village clinics, clinics, district hospitals (27 district hospitals and 23
mission hospitals), 4 central hospitals and 2 mental health hospitals 1]. Health facilities are managed by the Ministry of Health (MOH) (60%) or owned and
run in collaboration with the Christian Health Association of Malawi (CHAM) (40%).
The MOH aims to deliver healthcare services which are within their budgetary and human
resource means and aims to provide a basic package of evidence-based care for all
Malawians. Constraints to its implementation include weak health system support and
shortage of staff 2]. There are also inequities, with the wealthier accessing services more than the poor
3], 4]. The rural poor are particularly at risk for these health inequities 5]. The medical workforce in Malawi consists of non-physician clinicians (medical assistants,
clinical officer) and physicians or doctors (medical officers who are generalists
and specialists). The former cadres vastly outnumber the latter (see Table 1). Since 1991, doctors have been trained at one institution, the College of Medicine
(COM), and 500 medical doctors have graduated. An analysis of recent graduates between
2006 and 2012 showed a retention of 80% but with significant decay each year in the
number of graduates still working in the public system (around 50% after 5 years)
and less than one third working in rural areas, even shortly after graduation 6]. This is despite the allocation of new graduates to district hospitals 7]. Paediatric specialists working in the public health system in Malawi are located
in two of the four central hospitals in Blantyre and Lilongwe. There are no specialists
in two referral hospitals or in any of the district or mission hospitals. Since 2004,
the COM has been training specialists in paediatrics and child health. This cadre
receives 2 years training in Malawi and 2 years in South Africa. Upon passing their
professional examinations, these specialists generally take up consultant positions
in one of the four central hospitals.

Table 1. Location of paediatric specialists and clinical officers employed by the MOH

Malawi, like 25 other countries in sub-Saharan Africa, relies heavily on a cadre who
provide diagnostic and clinical services similar to doctors but who are not graduates;
they are often described as non-physician clinicians 8]. Malawi has two groups of non-physician clinicians, called clinical officers (COs)
and medical assistants (MAs). COs undergo 3 years of training, are awarded a diploma
in clinical medicine and serve an internship of 1 year. They offer a broad range of
expertise in clinical services, including assessing and treating a wide range of paediatric
and adult medical conditions, basic surgery and caesarean sections. MAs receive 2
years training, do not serve internship and do not perform surgery 9]. COs and MAs provide front line medical services in all specialities and at all level
of facilities. However, there is no clear career pathway for them to follow upon graduation.

Managed clinical networks

Managed clinical networks (MCNs) are hierarchically linked groups of professionals
and organizations, from primary, secondary and tertiary care, working together across
professions and ranks to ensure equitable provision of high-quality healthcare 10]. Successful development depends on the relationships which develop between the professionals
and organizations and ideally results in the optimal use of clinicians’ time at each
rank. The Royal College of Paediatrics and Child Health has articulated that MCNs
have been shown to ensure that the right care is provided as close to home as possible,
and clinical networks are fundamental to this aim 11]. A network may be focused on a specific disease or a specialty, and the principles
of networking services have been applied in diabetes care, paediatrics, cardiology
and vascular surgery. One paediatric model described strives to ensure the right balance
between local and specialized services for 400 000 children, and the successes include
the use of common standards for management hosted on a website which serves all professionals
and the joint ownership of clinical problems across secondary and tertiary providers
12]. The MCN model has also been used in Malawi in the context of the ear, nose and throat
(ENT) service. There is one ENT surgeon in the central hospital in the southern region,
who has trained 15 clinical officers in ENT, each placed in a district hospital. This
has resulted in bringing ENT expertise much closer to the patient with the opportunity
for the ENT CO in the district to discuss cases with the ENT surgeon and refer as
appropriate 13]. The expected outcomes of MCNs are improved access for those living rurally, equity
and quality of care and transfer of knowledge between health professionals with the
emphasis shifting from buildings and organizations to services and patients supported
by regular meetings and communication between clinicians, shared protocols and guidelines,
access to mentoring and regular audit 14]. Given the largely rural population and the scarcity of specialists in rural districts,
it is plausible that a managed clinical network model may confer advantages. We hypothesize
that paediatricians sharing their expertise within the model of a managed clinical
network may improve child health in Malawi.