However due to a decrease in the running costs of the overall programme the implementing partner Lighthouse has managed to operate a reduced programme for a fourth year concentrating on 10 of the busiest rural health centres surrounding Lilongwe.

The focus of this programme has been to ensure that everyone attending 31rural health centres is offered HIV counselling and testing, with a particular emphasis on pregnant women.

Given the success of the programme The Rose Project is actively seeking funds for a further two years.
Over the four year period 374,152 people have been tested. In a country where HIV is so prevalent, it is vital for everyone to know their HIV status.

The programme has confirmed that approximately 4% of the rural population are HIV positive with the rate rising 7% in three areas where there is substantial commercial activity. The increased prevalence is due to transactional sex.

18,000 of the general population who tested HIV positive have been referred for treatment and a further 4,700 pregnant women. Over the duration of this programme increasing numbers of men are coming forward for testing. This is a welcome change. In an effort to encourage this welcome trend, couples who come together to the health centres for testing - are seen first!

The programme is co- funded by Irish Aid, and has been implemented by Lighthouse an outpatient HIV clinic which was funded by The Rose Project in 2006

Early in 2011 during a visit to the programme it became apparent that there was a group of people who had not responded to medical treatment for HIV and were in the final stage of AIDS. The patients were dying alone without pain control in appalling conditions. These patients were in need of home based care with a palliative care dimension.

The Rose Project approached the Irish Hospice Foundation for a grant and was successful. Many patients are now benefiting from the programme who previously were struggling on their own in challenging circumstances associated with extreme poverty. The Palliative Care Association of Malawi have been helpful in the implementation of the programme.

The Rose Project has had a substantial input to this remarkable achievement through a rural programme which they co-fund with Irish Aid. This programme ensures that each expectant mother attending 31 of the rural antenatal clinics surrounding the capital city has access to HIV testing and where positive receives treatment. Over the past four years, approximately 4,700 HIV positive pregnant women attending these clinics were referred for treatment.

The single greatest challenge to healthcare delivery in Malawi is the acute shortage of health care workers. However great strides have been made over the past few years to overcome the problem evidenced by the fact that for the first time in decades the Labour ward at Bwaila Maternity Hospital is adequately staffed with midwives. The Malawian government has responded to the healthcare shortage by increasing the number of nursing and midwifery student intake at the University of Malawi.

Presently there are only 5 certified obstetricians /gynaecologists working in Malawi-some of whom restrict their work to the private sector.

In July this year, the first ever Malawian obstetrics/ gynecology residency training programme will begin. This will be implemented by the University of North Carolina and the Malawian College of Medicine. The Rose Project will also contribute to this programme.

The residency will be the first of its kind in Africa with fistula training forming part of the programme. This is important in a country where obstetric fistula is a major problem making life for many women intolerable due to the associated stigma.

The three hospitals participating in the Residency will be Bwaila Maternity Hospital Lilongwe, Ethel Mutharika at Kamuzu Central Campus Lilongwe and Queens Hospital in Blantyre.

The standard of care continues to improve at the hospital due to the increase in medical and midwifery staff. In addition there are now 2 obstetricians working at the hospital which is also having having a significant impact on healthcare delivery. Freedom from Fistula Foundation (Scotland) are funding these posts
The Rose Project and University of North Carolina, in partnership with the District medical/nursing teams continue to provide training courses for midwives at the hospital, the courses are not only raising the standard of midwifery but also the general morale amongst the staff.

The Rose Project continues to work with the Universities of North Carolina and Helse Bergen towards making Bwaila Maternity Hospital a safer place for women and their babies. Good news: despite the challenging number of births at the hospital, maternal mortality has dropped by 10% in the past two years. In addition the number of HIV positive women attending the hospital for delivery has dropped from 25% in 2006 to 12% in 2012. The reduction in HIV infection amongst pregnant women has been noticed by staff at the hospital, in that the general health of the women is improved and complications are marginally reduced. It is now well documented that HIV is a major contributory factor to maternal mortality and morbidity.

Visit to Lilongwe 22 September to 4th October 2012-Mary Donohoe

Bwaila Maternity Hospital

The new Bwaila maternity hospital is working well despite substantial challenges. In 2009 when Dr Mary Robinson and President Joyce Banda opened the hospital - there were 12,000 annual births.

The number of births annually over the interim three years has risen to 18,000. Bwaila Maternity Hospital is now the busiest maternity hospital in Southern Africa. The shortage of skilled healthcare providers remains the greatest challenge. At the moment there is one resident obstetrician, 4 clinical officers (a cadre of healthcare worker specific to Malawi) and four qualified midwives, in the labour ward at any given time.

Despite this, substantial progress has been made towards reducing maternal and infants deaths and improving the general standard of care for patients.

A number of International organisations have joined The Rose Project to improve clinical services including the University of North Carolina(UNC) the International Health Foundation (IHF) Centre for Disease Control USA (CDC) The Department for International Collaboration Norway and Freedom from Fistula Foundation Scotland.

Labour Ward Bwaila Maternity Hospital

The Labour ward is working well despite that fact that it is understaffed by 50%. Talking to the midwives, you are aware that they are under substantial pressure. The Rose Project has been responsible for running a number of training programmes in the labour ward over the last three years. These programmes provided by our representative midwife Rachel Macleod have been successful in raising the standard of care in the unit and also improving staff morale. The Rose Project, in partnership with the University of North Carolina, are also providing training in Emergency obstetric care (EMOC) and ultra sound.

In conversation with the principal of the College of Nursing at the University of Malawi, Dr Address Malatta, it is clear that the situation in relation to nurse/midwife training is improving-In 2008 the annual intake of nurses/midwives was 80 students. In 2011, the number has increased to 200. The increase will begin to impact on healthcare delivery in 2 years time.

Quality improvement in the area of clinical care is being monitored by MaiKanda, an organisation funded by IHF. Each month figures are released relating to infant and maternal mortality and areas of difficulty are gradually being addressed. Maikanda has also recently completed a survey identifying reasons for frequent absenteeism. This survey has lead to a rethink of staff allocation at the hospital. Previously staff did not have a say in where they worked-this has changed-resulting in improved morale.

The Fistula repair programme funded by Freedom from Fistula Scotland opened a new standalone unit in July 2012. They had previously been working from a ward within the new maternity hospital, due to demand for treatment, the unit required more space. The organisation renovated the old maternity hospital and a new operating theatre has been installed. So far 300 hundred women have had fistula surgery and there is a waiting list for a further 70. The fistula unit is located beside the new maternity hospital.

Part of the success of this programme lies in the fact that the media were invited into the fistula unit prior to its opening and given a briefing on the facility. The result in reaching women in need of care has been remarkable. In addition, those who have the surgery are spreading the word. Today I met a woman who had fistula repair surgery earlier in the year. She arrived back for a check-up with 12 other women who needed similar surgery. This inspirational woman now spends her days in the unit providing information and support to the women attending!

In addition to providing fistula repair, Freedom from Fistula has partnered with a number of local organisations to provide micro- finance (Opportunity Bank Malawi) and education. Eurotalk provides iPods, (complete with the Basic Primary Schools Curriculum app) for the women. During the recovery period the women are assisted with both these programmes.

Dr Jeff Wilkinson, the fistula surgeon working at the unit provides obstetric care to the maternity hospital when possible.

Finally, the remaining part of the old maternity hospital is now home to a new circumcision unit which is funded by I-TEC. Circumcision reduces the risk of HIV transmission and other sexually transmitted diseases substantially. The day care unit which opened in the middle of August, has carried out 300 circumcisions.

HIV Counselling and Testing in the rural Health Centres of Lilongwe 2008-2012

This programme in its fourth year, operates from 31 rural health centres surrounding Lilongwe. The focus of this programme is to ensure that everyone attending the heath centre is offered HIV counselling and testing, with a particular emphasis on expectant women.

Here we met the HIV counsellors responsible for implementing the programme. Despite the crowds waiting to be seen, the counsellors were managing well, making sure all patients were given adequate time. The Rose Project has been funding this programme for four years. So far, 374,152 people have been tested. The programme has confirmed that approximately 4% of the rural population are HIV positive with the rate rising to 7% in three areas where there is substantial commercial activity. The increased prevalence is due to transactional sex.

18,000 of the general population who tested HIV positive have been referred for treatment and a further 4,000 expectant women. Over the duration of this programme increasing numbers of men are coming forward for testing. This is a welcome change. Couples who come together to the health centres for testing, are given priority!

The programme co- funded by Irish Aid, and has been implemented by Lighthouse an outpatient HIV clinic which was funded by The Rose Project in 2006. The programme also links into the new maternity hospital.

The Family Health Unit at the hospital is overstretched and understaffed. Services offered include ante-natal care-family planning-early infant diagnosis for HIV -nutrition clinic-under 5’s assessment clinic-cervical cancer screening. The Rose Project is examining ways to assist with some of these services-particularly in the area of HIV management.

Wellness Centre Lilongwe In 2009 The Rose Project funded the Wellness Centre in partnership with the Malawian and Norwegian Nurses Associations. The centre is home to the Malawian Association of Nurses and Midwives. The impact of the HIV pandemic has taken its toll on nurses in Malawi both in terms of the numbers of nurses lost to the virus and the strain on those working in the public system. They have felt poorly remunerated and poorly supported.

The centre provides support to its members and also to families of nurses who have lost members to HIV. The association has been active in pursing better training and career opportunities for its members, and has also been successful in advocating members rights. Gradually the conditions for nurses and midwives are beginning to improve.

Palliative Care Programme Lilongwe

This programme is focused on improving the quality of life for people living with HIV and other life threatening illnesses by incorporating palliative care into existing home based care services. The programme is run by the Catholic Diocese of Lilongwe. All patients in the area are cared for regardless of religion. There are only two nurses available for the programme which covers a very large area. In an effort to address the shortage of healthcare staff - volunteers have been trained in the basics of Palliative Care. Many patients are benefiting from the programme who previously were struggling on their own in challenging circumstances associated with extreme poverty. This programme is co funded by The Irish Hospice Foundation.

In 2011 the hospital managed 14,000 births. The National Maternity hospital in Dublin, for the same period managed 9,500 births.

There are only 2 obstetricians in Bwaila Maternity and 20 fully qualified midwives. This principal challenge to safe births at the hospital and in Malawi in general is- the acute shortage of healthcare workers.

Bwaila Maternity hospital was funded by The Rose Project in 2009 replacing the old maternity hospital. For a number of reasons (including the building of an additional maternity hospital not far away) it was hoped that the number of patients attending the hospital would fall. However the number has in fact increased by three thousand annually.

Senior midwife tutor - Rachel Macleod, The Rose Project’s representative at the hospital, continues to teach the midwives and provide clinical care to the patients. Rachel, for the past three years has been actively working to assist the up skilling of midwives, in the area of clinical care delivery and management. This has taken place in partnership with the district Health officer and senior matrons at the hospital.
The impact has been substantial - manifesting itself in the reduction of maternal and infant deaths.

Good news: since the hospital was built a number of international partners have joined The Rose Project, in the effort to reduce infant and maternal deaths and improve the standard of clinical care provided to patients.

Among these partners are the University of North Carolina Chapel Hill -the Centre for Disease Control USA and Freedom from Fistula Foundation (Scotland). The latter opened a fistula unit at the hospital late 2010.

The Department for International Collaboration Norway who part funded the equipment for the hospital, continues to work with The Rose Project in the area of management training for the midwifery staff. This organisation are also funding a full time midwife at the hospital.

The partners together have implemented a number of new initiatives at the hospital including:
• A midwife clinical mentoring team
• Individual skills assessments and skills improvement for midwives
• New obstetric skills lab
• In service training for midwives
• Setting up of a hospital Library
• Norwegian exchange program and Management skills workshop
• Electronic register for admissions and discharges (Baobab International)

ACHIEVEMENTS in the Labour Ward

• 20 of the most experienced midwives have formed Bwaila clinical mentoring team. (BCMT) This team will ultimately be responsible for the supervision, training and mentoring of both full time staff and students, in the Labour ward.
• Three senior midwives travelled to Norway for a management training course and a follow up course will take place in Bwaila Maternity this year. Since their return there are signs that the labour unit is working more efficiently and there in a concerted effort to manage work rotas, shortages etc in a more efficient manner.
• Whilst BAOBAB International inserted the electronic system in the hospital last year , the midwives were not trained in its use. With additional funding, six IT technicians have been employed to work alongside the midwives 24/7 to orientate and support them through the initial months. It is proving to be very successful.

Lighthouse Outpatient Clinic (funded by The Rose Project in 2006)
Lighthouse clinic is situation next door to the Bwaila Maternity Hospital and works in partnership with the hospital in the area of prevention of mother to child HIV transmission. The workload at outpatient clinic continues to grow steadily, with over 4,000 visits per month. Approximately 234 HIV positive patients are commenced on treatment each month. 66% of the patient reviews are made by nurses, leaving the more complex cases for the few clinicians available. The acute shortage of healthcare workers is the principal challenge to healthcare distribution in Malawi.

HIV Counselling and Testing in Rural Areas (2008-2012)
This programme (co-funded by Irish Aid) is its fourth and final year. The aim of the programme is to bring HIV testing to the rural clinics surrounding the capital city of Lilongwe. A particular emphasis is on ensuring that all expectant women have access to HIV testing through the existing ante-natal clinics.

Overview of programme
A Joint initiative by TRP and Lighthouse in partnership with Irish Aid.

BACKGROUND HISTORY AND CHALLENGES
Approximately 30% of all new HIV infections are due to mother to child transmission.
In Lilongwe there are 90-100,000 births annually within a population of 1.5 million.
Of these 15,000 to 20,000 of babies are infected with HIV.
HIV status is known for fewer than 6% of births
There are still low numbers of HIV positive women receiving therapy at antenatal clinics (7%)
Main provider of PMTCT in Lilongwe University of North CArolin only provides 25% coverage.

PROJECT AIMS
Provide 50,000 HIV tests per annum tripling the number of women accessing HIV counselling and testing in antenatal settings in Lilongwe district from 25,000 to 75,000 thereby enhancing service provision and increasing coverage.

RESULTS
Total number of people tested 374,552
Total number of people referred for treatment 25,309

The Rose Bowl Sculpture commissioned in 2006 - Sponsored by D2
The Rose Project commissioned a sculpture of Rose Atieno in 2006 to commemorate her life and the 28 million lives lost due to the HIV on the African continent. St Stephens Green Park in Dublin was home to the sculpture for six years.

In June 201, the Office of Public Works indicated that they required the space for temporary exhibitions and invited us to find a new home for the sculpture.

The Board of the Rose Project are pleased to announce that the final ‘resting place’ for Rose will be in Dublin City University campus. Professor Brian Mac Craith accepted the offer of the sculpture indicating that it was a wonderful gift to the university.

Dublin City University will host an annual World AIDS Day lecture which will involve student participation.

DCU has a strong commitment to global health through a number of their schools particularly the school of Nursing which are involved in a Global Health Initiative with the Royal College of Surgeons in Ireland.

Current Political Situation
President Joyce Banda has already made a number of decisions which is likely to reinstate Aid from its principal donor - Britain. During the previous regime Aid had been cancelled due to corruption at the highest level of government. The official jet airline has been sold of with a number of Mercedes cars also being sold. Within the past week, The Malawian government has said it will not host an African Union summit in July because the continental body has insisted that Sudanese president Omar al- Bashir, wanted on charges of genocide, be allowed to attend the meeting.

The decision by Malawi’s new president, Joyce Banda, marks an about-turn in the country’s position towards Mr Bashir, who is wanted by the International Criminal Court for genocide, war crimes and crimes against humanity in Darfur.

Ms Banda’s predecessor, Bingu wa Mutharika, who died in office in April, had defied calls to apprehend Mr Bashir and allowed the Sudanese president to enter and leave the southern African country in October 2011.

In a recent letter to the Malawian government, the AU insisted that Mr Bashir be permitted to attend the summit, scheduled for July 9th to 16th, despite the arrest warrants pending against him. (Irish Times June 11th 2012)

From the health perspective, the new president has appointed Dorothy Ngoma as the government’s Safe Motherhood consultant. Ms Ngoma was been a huge force for change within the nursing and midwifery area and is acutely aware that unless the severe shortage of skilled healthcare attendants is address in Malawi, the tragically high number of infant and maternal deaths associated with giving birth will not be addressed.

April 19th 2012
President Joyce Banda is inaugurated as the new Malawian President. The country has been in the grips of an autocratic regime for the past number of years under the rule of Bingu Wa Mutharika. This has lead to immeasurable suffering for people requiring healthcare, due to shortages of medicines and hospital closures. Bwaila Maternity Hospital is grossly overcrowded, as many Christian Missionary Hospitals have been forced for financial reasons to close.

MARCH 2012.
Due to the ongoing political unrest in Malawi under President Mutharika essential drugs continue to be a huge challenge. Shortage of gloves, sutures, catheters, IV fluids and drugs have become a normal part of everyday life on the unit. Shortage of fuel continues to affect the provision of care to patients. Episodes without power due to fuel shortage continue. There were also long periods without a water supply in the month of April due to some important repairs on the main system. This was particularly challenging.

Increased financial support is required to reach the remaining 50% of HIV positive people who do not have access to treatment. According to figures released by UNAIDS March 2010:

• In Malawi 888,000 people are living with HIV
• Mother to Child is the second most common form of HIV transmission and accounts for 30% of all new infections

“Providing pregnant women living with HIV with antiretroviral prevention and treatment reduces the risk of a child being born with the virus to less than 5%—and keeps their mothers alive to raise them. (UNAIDS 2010)
Neither technical nor scientific barriers stand in the way of providing this treatment.

The University of North Carolina-Chapel Hill, has commenced a partnership with Bwaila Maternity Hospital -They join The Rose Project Ireland and Freedom from Fistula Scotland, in an effort to improve maternal and infant health in Lilongwe the capital of Malawi.

Despite ongoing political unrest, Bwaila Maternity Hospital continues to look after the majority of the births in the Lilongwe district. Many missionary hospitals have had to close their doors due to the uncertain political environment.

Rachel Macleod - The Rose Project’s midwife representative at the hospital, continues to work with the Malawian team in an effort to raise the standard of clinical care in the labour ward.

The hospital has recently acquired a full time Kenyan obstetrician and also a full time fistula surgeon.
The challenge remains to address the high level of maternal mortality. Malawi has the highest rate of maternal mortality in the world, for a non conflict country.

The acute shortage of midwives and obstetricians is one of the contributing factors.

With 14,000 annual births and only one obstetrician this is a challenge-The National Maternity Hospital in Dublin, has 16 resident obstetricians - and 9,500 births.(2010).

HIV has had a profound impact on maternal and infant health. 30% of all new infections are the result of mother to child HIV transmission during pregnancy.

Additionally, Malawi is a predominantly rural country and access to antenatal care is extremely difficult for women. Long distance and poor transport being the principal problems.

Fistula Clinic at Bwaila Maternity Hospital (commenced 2010)

140 women have had fistula repairs at Bwaila Maternity Hospital in the past year thanks to the work of the Scottish organisation Freedom from Fistula who are funding a Fistula Surgeon.

Obstetric fistula is the most devastating and serious of all childbirth injuries. It happens because most mothers in poor countries give birth without any medical help. So many are young girls. Complications from pregnancy and childbirth are among the leading causes of death and disability for women of reproductive age in these places. Obstetric fistula was eradicated in the United States more than 100 years ago thanks to emergency caesarean section surgery.

After enduring days of agonizing, obstructed labour a woman’s body is damaged by childbirth. During labour contractions, the baby’s head pushes against the mother’s pelvic bone — causing tissue to die due to lack of blood flow to this area. The pushing creates a hole, or in medical terms a “fistula”, between the birth passage and an internal organ such as the bladder or rectum. A woman cannot hold her urine, and sometimes bowel content as well.

Her baby is unlikely to survive. If she survives, a woman with fistula is likely to be rejected by her husband because of her inability to bear more children and the odour created by the condition. She will be shunned by her community and forced to live an isolated existence. These women suffer profound psychological trauma resulting from the loss of status and dignity, in addition to suffering constant pain.

The clinic is situated next door to the new Bwaila Maternity Hospital in the centre of the capital city- Lilongwe. Both institutions work closely together, particularly in the area of prevention of mother to child HIV transmission in pregnancy.

Since the opening of the clinic:
54,340 people have been tested for HIV and counselled in relation to the virus

Number of people placed on treatment for HIV:

• 12,340 women and men
• 1198 expectant HIV positive women
• 196 children
• 5889 patients have received treatment for TB

In 2008 Lighthouse OPD Clinic and The Rose Project were keen to expand the clinic services out to the rural healthcare clinics surrounding Lilongwe.

This programme, co-funded by The Rose Project and Irish Aid is in its fourth and final year .

• 331,000 people have been tested for HIV and counselled
• 15,000 people placed who tested positive placed on treatment
• 5,000 HIV positive expectant women placed on treatment

331,000 people have been tested for HIV in the rural healthcare clinics surrounding the capital city. In a country where the incidence of HIV is high- it is important for everyone to know their HIV status.

Lighthouse Clinic is responsible for 42% of all HIV Counselling and testing and encounters in the Lilongwe District over the last three years These are remarkable figures!

Once tested, people are advised on how to remain negative - those who test positive, where possible - are offered treatment at the clinic, failing this they are referred to another clinic where the treatment is available. Unfortunately HIV treatment is not available all the health clinics due to logistical difficulties such as staff shortages.

The Rose Project home page shows healthcare workers heading out from lighthouse clinic to the rural areas on motorbikes(funded by The Rose Project).