Scaling-up the MSF France HIV/Aids programme in Chiradzulu, Malawi, through decentralization and task-shifting 1993-2012

Background:
MSF have been providing HIV care in Malawi for 19 years, 11 of them through ART. Today nearly 30,000 patients are alive on ART in the project. Thus MSF is no longer just demonstrating that it is possible to provide HIV-treatment to poor people in high-prevalence countries, as originally planned, MSF has morphed into a public health provider.

Purpose/objective:
The study is an attempt to tell the story of the Chiradzulu project, from its beginning until 2012. The aim is to explain the evolution of health care delivery through scaling-up of treatment using decentralisation and task-shifting.

Methodology:
The report use semi-structured interviews with key project staff from the entire history of the project.

Key findings:
The rapid increase in patients under treatment was firstly facilitated through the simplification of the treatment approach. Compared to the approach previously taken in developed country settings, the testing regimen was dramatically simplified in Malawi, allowing for greater scale-up.

Secondly scale-up was facilitated through decentralization of care. From an initial hospitals based approach, ART care was delocalised to ten district health centres where MSF implemented regular mobile clinics.

Finally scaling-up was helped by task-shifting. Instead of leaving HIV-care to medical doctors, who were in short supply, MSF trained clinical officers and nurses from both MSF and MOH to take over HIV-care of stable patients and enrol new patients.
The change in treatment approach was complemented by the implementation of a six-month appointment strategy in 2007. The strategy reduced the number of consultations for stable patients, reducing the workload on health structures at the same time.

Recommendations:
The evolution of HIV-care in Malawi has transformed MSF from an innovating partner, eager to demonstrate the possibility to provide previously inaccessible HIV-treatment to people in developing countries, to a public-health provider. MSF does not have the expertise, nor consider it to be its mission to take on this role permanently. MSF is therefore looking for a hand-over partner.
The size of the cohort has on the other made hand-over very difficult. The Malawi health system is not yet able to take full responsibility for the cohort. Thus hand-over will have to be staged over several years while MSF also will have to start for looking for private funds to supplement MoH resources.

Comments from the organisation, if any:
NA