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Abstract

The migration of health professionals from southern Africa to developed nations is negatively affecting the delivery of health care services in the source countries. Oftentimes however, it is the reasons for the out-migration that have been described in the literature. The work and domestic situations of those health professionals continuing to serve in their posts have not been adequately studied. The present study utilized a qualitative data collection and analysis method. This was achieved through focus group discussions and in-depth interviews with health professionals and administrators to determine the challenges they face and the coping systems they resort to and the perceptions towards those coping methods. Health professionals identified the following as some of the challenges there faced: inequitable and poor remuneration, overwhelming responsibilities with limited resources, lack of a stimulating work environment, inadequate supervision, poor access to continued professionals training, limited career progression, lack of transparent recruitment and discriminatory remuneration. When asked what kept them still working in Malawi when the pressures to emigrate were there, the following were some of the ways the health professionals mentioned as useful for earning extra income to support their families: working in rural areas where life was perceived to be cheaper, working closer to home village so as to run farms, stealing drugs from health facilities, having more than one job, running small to medium scale businesses. Health professionals would also minimize expenditure by missing meals and walking to work. Many health professionals in Malawi experience overly challenging environments. In order to survive some are involved in ethically and legally questionable activities such as receiving "gifts" from patients and pilfering drugs. The efforts by the Malawi government and the international community to retain health workers in Malawi are recognized. There is however need to evaluate of these human resources-retaining measures are having the desired effects.
BioMed Central
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BMC Health Services Research
Open Access
Research article
How are health professionals earning their living in Malawi?
Adamson S Muula*
1
and Fresier C Maseko
2
Address:
1
Department of Community Health, University of Malawi, College of Medicine, Blantyre, Malawi and
2
Department of Basic Studies,
Malawi College of Health Sciences, Lilongwe, Malawi
Email: Adamson S Muula* - muula@email.unc.edu; Fresier C Maseko - fcmaseko@yahoo.com
* Corresponding author
Abstract
Background: The migration of health professionals from southern Africa to developed nations is
negatively affecting the delivery of health care services in the source countries. Oftentimes
however, it is the reasons for the out-migration that have been described in the literature. The
work and domestic situations of those health professionals continuing to serve in their posts have
not been adequately studied.
Methods: The present study utilized a qualitative data collection and analysis method. This was
achieved through focus group discussions and in-depth interviews with health professionals and
administrators to determine the challenges they face and the coping systems they resort to and the
perceptions towards those coping methods.
Results: Health professionals identified the following as some of the challenges there faced:
inequitable and poor remuneration, overwhelming responsibilities with limited resources, lack of a
stimulating work environment, inadequate supervision, poor access to continued professionals
training, limited career progression, lack of transparent recruitment and discriminatory
remuneration. When asked what kept them still working in Malawi when the pressures to emigrate
were there, the following were some of the ways the health professionals mentioned as useful for
earning extra income to support their families: working in rural areas where life was perceived to
be cheaper, working closer to home village so as to run farms, stealing drugs from health facilities,
having more than one job, running small to medium scale businesses. Health professionals would
also minimize expenditure by missing meals and walking to work.
Conclusion: Many health professionals in Malawi experience overly challenging environments. In
order to survive some are involved in ethically and legally questionable activities such as receiving
"gifts" from patients and pilfering drugs. The efforts by the Malawi government and the international
community to retain health workers in Malawi are recognized. There is however need to evaluate
of these human resources-retaining measures are having the desired effects.
Background
The shortage of health professionals in almost all of the
African health systems has received international recogni-
tion [1-3]. African health systems already inadequate to
deliver health services to meet the goals of Primary Health
Care (PHC) as agreed in Alma Alta in 1978 and the Mil-
lennium Development Goals (MDGs) have been over-
stretched even more with the demands and consequences
Published: 09 August 2006
BMC Health Services Research 2006, 6:97 doi:10.1186/1472-6963-6-97
Received: 02 April 2006
Accepted: 09 August 2006
This article is available from: http://www.biomedcentral.com/1472-6963/6/97
© 2006 Muula and Maseko; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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of the HIV and AIDS pandemics [4,5]. Although outward
migration of Africa's professionals is not a new phenome-
non, and has been occurring due to several years, the
effects of the migration in the past several years has been
unprecedented. The reasons behind the migration of
health professionals from Africa to mostly developed
nations, especially Australia, Canada, the United States,
United Kingdom and New Zealand, have been described
[6-8]. These have been categorized as "push factors" and
"pull factors". The "push factors" are those factors operant
in the African "donor" country from which health profes-
sionals are living. The "pull factors" are the green pastures
and other activities that influence recruitment in the
"recipient" western developed nations [3]. The Regional
Network for Equity in Health in East and Southern Africa
(EQUNET) have described the migration of African health
professionals to northern countries as "reverse subsidy",
as African countries are increasingly becoming a formida-
ble and unwilling donor community of health profession-
als to developed nations, many of whom are members of
the G7 [9,10].
Although the issue of Africa health professionals' migra-
tion to northern countries has received attention by the
research and academic community, policy makers and the
wider community, oftentimes the discussion weighs more
on what are the issues that are responsible for this "brain
drain" of Africa's resources. Not that this is not important,
but rather it is just part of the whole picture. In most Afri-
can health systems, the proportion of health professionals
that have migrated out of the continent, although a large
number, are still the minority of all the health profession-
als that the concerned countries would have had. Not
much attention has been spent on describing how those
health professionals that have not left their posts in Africa
are earning their living. In order to contribute to the liter-
ature on the African brain drain, we conducted a qualita-
tive study of Malawi as a case study, with the following
specific objectives: a) determine the sources of income for
health professionals in both private and public services in
Malawi other than formal wages (pay salaries); b) deter-
mine working practices of health professionals in Malawi
that may influence their retention in the country; c) deter-
mine attitudes of health professionals towards various
forms of out of formal employment incomes; d)identify
possible strategies that could contribute to retention of
staff and have a positive impact on the problem of brain
drain in Malawi.
Methods
This study utilized focus group discussions and in-depth
key informant interviews. The study participants included
health professionals and administrators working at health
centres, district level as well as the Ministry of Health
(MoH) headquarters. In total, 35 nurses, 15 doctors, 25
clinical officers, 15 medical assistants, 40 technical sup-
port staff and 15 administrators and policy makers were
interviewed. This method was deemed necessary for col-
lecting data in an exploratory way as has been described
by Morse [11].
Study participants were identified both purposively and
through convenience sampling. At the level of the Minis-
try of Health and hospital management study participants
were mainly identified purposively as participants were
interviewed by virtue of their position. Other health pro-
fessionals were interviewed based on their availability at
the time of visit to the health facility. At the health facili-
ties visited the officer-in-charge, matrons and ward sister-
in-charge were requested to assist in identification of
potential participants. This would have introduced bias as
the persons assisting in identification of potential partici-
pants may have favoured or selected against certain indi-
viduals. However, noting that even if that were the case,
themes obtained were repeated at distant sites may sug-
gest that the information obtain could be generalized to
No attempts to interview were made towards health pro-
fessional who were not available at time of interview.
Health professionals from all three regions of Malawi
(south, center and north) were interviewed. Interviews
were noted on paper and were not recorded the perceived
sensitivity of the topic needed assurances that participants
identities could not be inadvertently revealed. Data were
analysed manually based on literature reviewed and
emerging from the interviews based mainly on challenges
being encountered, efforts to cope within such an envi-
ronment and the perception held towards those survival
mechanism. This was done by identifying repetitive. Liter-
ature was searched at the study design stage to guide in
formulation of relevant questions for the interview
guides.
Ethics and participants consent
Overall permission to conduct the study was obtained
from the Ministry of Health and Population (MoHP). At
each of the sites visited, the officer-in-charge also gave
assent after being explained the objectives of the study.
Study participants gave verbal informed consent. Partici-
pants' details were recorded only by their designation e.g.
nurse, clinical officer and no names were recorded.
Results
Various themes emerged from the interviews and the liter-
ature searches on the retention and survival mechanisms
of health professionals in Malawi. In general, the follow-
ing themes were identified; challenges faced health pro-
fessionals, survival strategies and perceptions towards the
survival strategies. The sub-themes under challenges faced
included; inequitable salaries and recognition of experi-
ence, overwhelming responsibilities, lack of stimulating
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interaction in the workplace, inadequate supervision,
impact of HIV and AIDS, limited access to further training,
limited career recognition, lack of transparency in recruit-
ment of staff, and discriminatory remuneration. The sub-
themes under survival strategies included ways of mini-
mizing expenditure and increasing income.
survival strategies which included efforts to increase
income and means to reduce personal and household
expenditure.
Challenges faced by health professionals
Challenges faced by health professionals in Malawi fall
into those that impact on work status and remuneration,
working conditions, opportunities for further training/
advancement and unfair recruiting practices.
Inequitable salaries and recognition of experience
In case of medical doctors, when the College of Medicine's
first graduates completed their internships in 1994 all of
them were sent to districts to work as district health offic-
ers (DHOs). This was the first largest group of Malawian
doctors to be deployed to districts at any one time. This
practice continues and newly qualified doctors upon com-
pleting their internships are posted as DHOs. This how-
ever creates a situation where much more experienced
DHOs who have worked for several years may be at the
same grade as those just coming in with no experience,
and remunerated at the same grade with the same privi-
leges. A doctor who had stayed in a rural district post for
many years said:
"I have served as a DHO for many years. Someone has just
come in from internship. We are at the same grade. What is
that?"
This was perceived by the long-serving doctor as unfair
and de-motivating. There was perception that doctors
coming in straight from medical school ought to be at a
lower scale than those that had served in their posts for
several years.
Nurses felt that they were marginalized by the MoH and
other employers in favour of medical doctors, clinical
officers and medical assistants. Of particular note, in
Malawi is that these other health cadres (clinical officer,
medical assistant) are predominantly male dominated
while the nursing field is female-dominated [12,13]. For
instance, doctors within the Christian Health Association
(CHAM) health facilities were eligible for salary supple-
mentation from the Germany government's Deutsche
Gessellschaft fur Technische Zusammenarbeit(GTZ) Gmb
funding which may be in excess of US$ 300 each month,
nurses on the other hand were not accorded no such priv-
ileges.
While DHOs were in many cases doctors and in a few
cases clinical officers, it seemed that no nurse, even those
with a degree, could be appointed a DHO. Interestingly
though, clinical officers, in some cases not as well trained
as the degree nurses, could be DHOs. This inevitably
resulted in discontent among degree nurses who ended up
being subordinates to clinical officers and medical assist-
ants. Registered nurses also felt humiliated in situations
where they were subordinates to medical assistants, who
had two years of professional training as opposed to the
degree nurses' four to five years. A newly graduated medi-
cal assistant (MA) could be sent to a health centre and be
in charge of that health center, responsible for all the sup-
plies and operations at that unit, including supervising
the nurse, (in some cases a registered nurse) who may
have been at the health facility for many years.
As one nurse said:
"What is painful is that even myself as a degree nurse must
work under a medical assistant who has a mere two year certif-
icate."
Situations like those stated above were reported to be
sources of frustration and resentment towards the health
care system.
Overwhelming responsibilities
Health professionals in Malawi reported finding them-
selves taking up responsibilities that were beyond what
their training and/or experience had equipped them for.
In many other cases, the equipment or supplies required
to enable them perform their duties so as to deliver high
quality health services were not available. In the case of
doctors who complete their internships and desire to con-
tinue working in the public health sector, many are sent to
work as DHOs expected to provide both clinical and
administrative leadership for an entire district, with little
experience for such challenging situations. Some districts
have population greater than 400,000 but still with fewer
health workers and facilities to enable full coverage of
services.
The situation was little different for degree nurses who are
sent to district hospitals. There are just a few nurses that
are sent to rural districts and many actually serve at the
district hospital itself. The degree nurse is likely to be
appointed a ward sister-in-charge, an acting matron or in
some cases even a matron, working as the district nursing
officer. While the health professional is trained at KCN to
take up such responsibilities at the appropriate time after
having acquired the requisite experience, the urgency to
take on such responsibilities without first having gained
experience can easily lead to frustration and burn out.
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While study participants recognized that being put in
administratively demanding jobs was a problem, they
also recognized that it was difficult not to appoint degrees
nurses or the only medical doctor in the district to very
senior positions. Related to this was the fact that invita-
tions to workshops, seminars and conferences, and there-
fore opportunities to access allowances/per diems usually
went to these senior cadres. The new degree nurse may
therefore feel pressured to attend to all these meetings,
thus leading to burn out.
Lack of stimulating interaction in the workplace
Health workers in the public sector in rural Malawi
reported working in isolation due to the low number of
other health professionals in the same locality. It was not
uncommon to have the only doctor in a particular district
as the DHO, and many districts having the only labora-
tory technician or radiographer with no other employees
in the same profession. There were only a few registered
nurses in each district, and the situation was similar for
other cadres. In many cases the professional isolation
implies an environment that was not challenging due to a
lack of peer support and sharing of ideas, resulting in frus-
tration because of the lack of professional interaction. The
lack of academically and professionally challenging envi-
ronment was exacerbated by the absence of any require-
ment for continued professional development (CPD) or
professional medical education (CME). CME is a process
operation in many countries, especially developed
nations where the health professional is required by law
to demonstrate active acquisition of knowledge or updat-
ing one's skill in order for re-registration by the regulatory
and professional bodies to occur. As there was require-
ment for continued professional development as a neces-
sity for re-registration by the regulatory bodies, health
workers felt there were not being "pushed" to maintain
excellence.
Inadequate supervision
Supervision is perceived to be a motivating factor by
health workers. Workers in this study reported they were
either poorly or inadequately supervised. Those that were
supervisors reported that lack of resources and especially
transport to rural remote areas coupled with other com-
mitments and responsibilities prevented them from mak-
ing supervisory visits. In some cases lack of the requisite
training and experience in undertaking supervision
seemed to result in poor understanding and appreciation
of the importance of supervision. It was felt that in order
not to expose their shortcomings, some supervisors at
times desisted altogether from undertaking any supervi-
sion. Lack of supervision, resulting in workers feeling
unappreciated, de-motivated and frustrated, was an
acknowledged reason health workers were not interested
to work anymore within the public health sector.
Impact of HIV and AIDS
There was a general perception among health profession-
als that they were at an increased risk of occupational
exposure to HIV and other infectious diseases, such as
tuberculosis. Although almost all health facilities had a
focal person responsible for universal precautions against
hospital acquired infections the availability of supplies
such as disinfectants was not universally guaranteed.
Apart from occupational exposure to HIV, it was likely
that a significant number of health workers were infected
with HIV although HIV prevalence figures among health
workers in Malawi are not available. In 1999, the Health
Sector Human Resources Plan reported the following
losses due to death: registered nurses (2.7%), clinical
officers (2.1%), medical assistants (2.1%), and 1.9% for
all enrolled nurses/midwives [14]. Although the Health
Sector Human Resources Plan did not indicate the distri-
bution of causes of deaths among the various health cad-
res, AIDS is likely to be an important factor. Shisana et al
reported that HIV prevalence among health workers in
South Africa was 15.7%, with younger health workers
(18–35 years) having a much higher prevalence of 20%
[15]. Tuberculosis infection rates among health workers
in Malawi are higher than the general community [16].
While there is all likelihood that tuberculosis acquisition
in caring of patients is higher for health workers, many
people do not normally think that the suspected high
rates of HIV among health workers is due to transmission
from patients to health workers.
The heavy work load coupled with the perception of
increased risk of getting an infection (HIV, tuberculosis),
result in some health professional changing from clinical
to other duties, or leaving the health profession alto-
gether.
Limited access to further training
Many health professionals valued access to further train-
ing. Employment as a junior faculty member within a uni-
versity department (at the Kamuzu College of Nursing
and the College of Medicine) almost always guarantees
the opportunity to obtain a postgraduate qualification,
either from the institution itself or from another institu-
tion. Sponsoring agencies and government are more likely
to support postgraduate training for a university employee
than for a health professional working in a non-educa-
tional institution. This offered as an attraction for employ-
ment in the training institutions for those health
professionals who desired to obtain higher qualifications.
Tutors in health training colleges are normally employed
when they have three year diploma and they thus have an
opportunity to obtain advanced or higher diplomas as
well as degrees. In the case of the Malamulo and the
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Malawi College of Health Sciences, one of the challenges
however is the fact that many of these degrees obtained by
tutors are not in mainstream clinical training but rather in
areas like health education. Such qualifications are mostly
good for the teaching position but little recognized by the
public sector to facilitate advancement in mainstream
clinical jobs.
Previously with limited numbers of health professionals
competing for training posts, the pubic health sector was
competitive in as far as providing or facilitating training
fellowships/scholarships. While this continues to occur,
there are many more health professionals requiring such
training and demand can hardly be met.
Unfortunately it would seem also that blocks are occur-
ring at MoH headquarters and that some do not support
the provision of postgraduate qualification to MoH
employees. A case in point would be the handling of
World Health Organisation's training fellowship from the
WHO's Malawi office. Malawi should receive, up to 20
WHO-funded training fellowships every two years from
the WHO Malawi office. Despite the availability of this
facility, the MoH has dragged its feet since 2002, imped-
ing Malawian health workers' ability to benefit from such
opportunities, and thereby removing a reason to remain
within the public health sector.
The College of Medicine has, from 2005 started providing
specialist degree course in several the core clinical special-
ties of Internal Medicine, Surgery, Obstetrics and Gynae-
cology and Surgery. Graduate public health training was
started much earlier in 2003 [17]. Currently however this
training in the clinical specialist programs is only availa-
ble to employees of the MoH and College of Medicine.
Private sector employees are not eligible. This may be an
incentive for doctors to work in the public sector. How-
ever, for those in the private sector, the only opportunity
for training is available outside the country.
Limited career recognition
Access to further training can be a motivating factor assist-
ing in the retention of health professionals. However,
when a health professional has acquired additional qual-
ifications, they require appropriate recognition for their
achievement. In several instances, the MoH does not seem
to accord this expected recognition to a staff member.
Frustration and resentment set in and the health profes-
sional may leave. Several medical doctors obtained post-
graduate qualifications abroad in Public Health/Epidemi-
ology. Upon return, these health professionals, who had
left as DHOs, seemed to have expected promotion to
higher MoH positions. When this did not happen, a few
stayed on leave for several months while they negotiated
with the MoH for their posting while others resigned.
The MoH is not solely responsible for the lack of recogni-
tion for its staff since it can only promote its staff to P5
grade, a level already attained by several DHOs. Promo-
tions above this grade are the prerogative of the Office of
the (State) President, i.e. political appointments. In
essence, what the system can do is that it is possible for a
health professional to be promoted to P5 grade and
beyond that it is the State President's who must do that.
Coupled with the need for further promotions to be
effected by the Office of the President, established posts
may not be available for an employee who has upgraded
themselves. Currently, the posts within the civil service are
established centrally, with significant guidance from the
Department of Human Resources (DoHR) of the central
government. The DoHR receives many requests from all
government departments for creation of new posts. It
must consider both the short-term and long-term finan-
cial implications of creating new posts. In many cases,
establishment of new posts can not be created and a
health worker who has acquired further training may have
to be wait until the holder of the position leaves the civil
service in any way.
Lack of transparency in recruitment of staff
There was a perceived lack of transparency in the recruit-
ment of health professionals. Health professionals
reported that even in some public institutions there were
no public advertisements for posts but rather a process of
headhunting had occurred. A doctor reported:
"What you first hear is that there is a vacancy and so and so
has been earmarked for such a post. At first, you think it is not
true. Let me apply for the post. You are not successful but to your
surprise, the candidate whom people said would take the post is
the successful one. Now I don't think I can apply for a job there
anymore."
Even when the advertisements are placed there is still an
expectation that an individual has been earmarked for the
post. This suspicion was reported as often proven correct
with the identified individual being recruited. Among the
reasons given for the absence of public advertisements by
the employing institutions was the lack of money for
adverts and the reasoning that "even if you advertise, people
will still not apply for the post."
Whatever the reasons behind such a practice, some health
professionals indicated that such practices are de-motivat-
ing. Many just remain in the public service in order to gain
work experience before moving on [18].
Discriminatory remuneration
Respondents indicated that one area that they find frus-
trating is in receiving much lower remuneration packages
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than expatriate technical support staff who in some cases
may have the same or even a lesser qualification and expe-
rience. Respondents noted that they could understand
"reasonable" differences in remuneration between
national and expatriate staff "up to a degree but not to a level
where one is tempted to think that nationality matters".
Survival strategies for health workers
Health workers have adopted various strategies ranging
from what can be described as legal through the unethical
to criminal behaviours to survive poor conditions and low
pay. A number of strategies require the health worker to
take on additional responsibilities either in or outside the
health sector, while others require varying degrees of per-
sonal denial. Several of these coping strategies do occur as
a result of inefficiencies within the health system while
some are only possible because of poor governance. The
survival strategies can broadly be grouped into two cate-
gories i.e. increasing income and minimizing expenditure.
Increasing income
In this category, health workers' actions that provide them
opportunity to earn more will be discussed.
Working closer to home villages
Many Malawians working in the formal employment sec-
tor are also involved in farming. Some health profession-
als, even when they do not work in their home districts
choose to work in a district close to their home village.
This accords them opportunity to farm in their home dis-
tricts should they wish to do so. Farming was identified as
one way for health professionals to earn extra money
through the sale of farm produce; to reduce expenditure
on food; and to support relatives who may be provide
labour on the farms.
Stealing drugs
It is often reported that significant quantities of drugs sup-
plied to the public health sector end up being pilfered and
sold. While unknown robbers are among the culprits,
some health workers are reported to be involved in steal-
ing drugs and selling them to drug vendors or private clin-
ics [19]. Some pharmacy assistants and technicians in
particular are reported to be heavily involved. This prac-
tice has been reported in many other African countries
[20].
In order to curb the diversion of drugs the government
introduced labeling of drug tablets with the letters "MG".
However, this has not had the required effect, and drug
thefts continue to be discharged at the courts "for lack of
sufficient evidence" even when culprits have been caught
with tablets with "MG" labels. An administrator in the
MoH said:
"Much of the drugs are stolen by pharmacy personnel them-
selves. This is a fact. Now, even when you catch someone red-
handed, it does not get very far. The culprit gets bail the next
day and you can never win a case like that. Even the judges and
the lawyers say the MG on the tablet could mean Margaret
Gama. This is absurd."
Another administrator was rather sympathetic:"It ought to
be known that if you cheat when paying someone, s/he will also
cheat you when s/he can. The pharmacy staff are stealing med-
icines, the administrators are running from one workshop to the
other while some don't report for duty. Pay them well and these
evils will reduce."
The practice of stealing drugs as a known occurrence
within the Malawi Ministry of Health has also been
reported by Chaulagai et al [21]. These authors reported
that at workshop by the MoH, the Minster mentioned
about the issue but did not address the matter signifi-
cantly although the MoH was aware of which health pro-
fessionals were culprits in this practice.
Short-term and long training
Health professionals who enroll in either short-term or
long-term sponsored training programs have the opportu-
nity to enhance their financial situation. These training
programs come with reasonable living allowances that
enable the employee and their family to live comfortably
and may contribute to the acquisition of household prop-
erty and/or fixed assets.
A lack of promotional opportunities for enrolled nurses
has resulted in some training as psychiatric nurses or as
anesthetic clinical officers. An enrolled nurse who trains
as a psychiatric nurse is promoted from her TA grade to a
TO (diploma grade). However many trained psychiatric
nurses are no longer providing specialist psychiatric care
but rather are employed in units or hospital departments
providing routine care where there may not be as much
need for specialist psychiatric training. In contrast, many
medical assistants who have benefited from training in
orthopaedics and anesthesia contribute significantly in
the provision of specialist services. The bulk of anesthetic
services in Malawi are provided by anesthetic clinical
officers who have upgraded from being medical assistants.
Allowances/per diems from meetings
Per diems and reimbursements for real and potential
expenses incurred or expected to be incurred for attending
workshops, seminars and conferences are important
sources of extra-salary income for health professionals
who have the opportunity to participate in such meetings.
Some meetings provide 'reasonable' per diems which
more than cover the expenses incurred, enabling health
professional to have extra cash to take home. Even when
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the per diems are not as lucrative, savings can be made by,
for instance, having a heavy breakfast or lunch when these
are already included in the conference package and only
having to pay for a lighter meal later.
Health professionals also make money from attendance
to meetings through reimbursements for approved
expenses. For example senior cadres may use their own or
MoH vehicles and get fuel reimbursements. When using
their own vehicles, over-estimation of fuel costs result in
extra money to the health worker. When using an institu-
tional vehicle and institutional fuel, the health profes-
sional may collect the reimbursement on behalf of the
institution, but may not reimburse the institution. One
reason given for such failure to take back the reimburse-
ment is that there is currently no mechanism which would
allow money to be deposited back into government
accounts (for public service employees). The other reason
given was that "everyone knows about this" and if you try to
reinforce reimbursements to the institution, "you are
unlikely to get any support from anyone."
The possibility of getting extra money from attendances at
meetings is perceived to be the reason why some senior
cadres are continually traveling from one meeting to
another even when the agenda would have been more
applicable to another health professional. This results in a
perception among the junior cadres that they are only sent
to the less lucrative meeting while their seniors are
monopolizing attendance of out of station, better paying
meetings.
Workers in senior management either at MoH or district
level may also 'frog-leap' from one workshop to the other,
even when the meetings are running concurrently.
According to one health professional:
"What you have to do is just be available for sometime, register
for the workshop and move on to the next workshop that you
have been invited. In so doing, you are assured of the allow-
ances."
It was also reported that when workshops are being con-
ducted at the local institution, the senior management are
all implicitly invited to attend to give their "blessing" to
such meeting. One clinical officer indicated:
"The DHO is the overall in-charge of the district. Although s/
he may not be physically at the workshop, he is spiritually with
you and so s/he deserves the allowances."
The instances discussed above have potential to augment
the health workers' salaries.
Locum/part-time duties
Locum and part-time work for health professionals is one
other way of making extra money. Ferrinho et al have
described the practice of working in both the public and
private health sector as "dual practice"(22) Professional
qualifications and the particular needs of the clinic or hos-
pital influence the cadre of staff employed for part-time
duties. Large private hospitals may hire anesthetic clinical
officers and radiographers but do not hire clinical officers
or medical assistants in favour of doctors. Nurses are likely
to be hired by smaller private clinics for part-time duties.
Institutions normally serviced by doctors also hire locum
doctors, some of whom are still doing their internships,
contrary to Medical Council of Malawi (MCM) regula-
tions. Although the MCM requires that a health profes-
sional should have clearance from their main employer
for locum practice and an individual private practice
license, many workers do not get the necessary employer's
authorization neither do they have the MCM private prac-
tice license. The lack of awareness of such requirements
and the high cost of the license underlie non-compliance.
Some health professionals, especially clinical officers, are
proprietors of private clinics where they employ full-time
or part-time staff, and also consult themselves out of
hours. In some cases, this has attracted reprimands from
the MoH Clinical services department who have felt that
staff neglected MoH duties in favor of their personal inter-
ests at the private clinics. There is also a perception that
some of the drugs and pharmaceutical supplies used at
these private clinics owned by MoH employees have been
pilfered from the public sector.
Some health professionals teach part-time at training
institutions for para-medicals and nurses. An individual
may even double their income this way as part-time pay
may be lucrative.
Change of work station
In order to make extra money some workers request trans-
fer from one type of work environment to another either
to facilitate off-duty clinic work or to allow travel to other
places during off-duty days. Employment in a unit that
only operates during day working hours allows for out of
hours part-time work at a private facility. Employment in
a district or central hospital in a ward where there are
shifts, allows for several full days off in a month which can
be used for personal income generation activities.
Over-time work at public health facility
The shortage of health workers in most of government
health facilities necessitates overtime work often paid for
from user-fees. Mzuzu Central Hospital, for example
makes provision to hire its own staff for part-time duties.
Over-time creates opportunities for those who would oth-
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erwise have been off-duty, to work. Even though the
money may not be substantial the income from overtime
may comprise a significant proportion of a worker's
income. There are however concerns as to the quality of
health services that can be delivered by exhausted staff
who are driven just by desire to make more money but
may not be fit to work.
Treating private patients during official work hours
Some health professionals who are fully employed in the
public health sector treat private patients during work
hours either at their private clinics or even within public
health facilities. Patients are required to pay for services
provided at the public health facility in exchange for being
attended to much faster than would have normally been
the case. Some health professionals do receive gifts from
patients and/or relatives in order to facilitate procurement
of services such as blood for transfusion, speedy consulta-
tions and clinical reviews.
Double salaries and supplementation
Almost all health professionals are guaranteed employ-
ment into the public sector when they graduate from the
training institutions in Malawi. In fact, students in the
health professionals most often are identified for work
stations before they receive their final examinations
results. The public sector is therefore the natural first
employer of potentially all health workers in the country.
From the public sector, health professionals then move to
other job positions, including the training institutions,
which can be described as quasi-state organizations as
they are mostly run with state financial resources. Some
health workers do not formally resign from the public sec-
tor and may continue to receive public sector salaries
despite the fact that they are no longer employed.
A different situation occurs when a health professional is
still employed within the public sector but has been trans-
ferred to another district. It may take a long time for that
person to start receiving their salaries from the new unit.
One administrator talking about workers who are still in
the public sector but have moved to new work stations
said:
"You do not normally remove a person from the payroll once
they have transferred to another station because it takes long for
them to start receiving their salaries from their new work sta-
tion. Now, you do not know when they have started receiving
at their new site. Many people continue receiving salaries from
their previous work stations and I am discovering that some are
also receiving salaries at their new station."
There are also reports of workers within health units and
training institutions benefiting from a multiplicity of sal-
ary supplements from donors who are unaware that a
worker is already in receipt of another supplement.
Consultancy duties
Skilled health professionals are able to undertake consul-
tancy research and/or training duties on behalf of the
MoH, donor agencies, NGOs and other institutions. This
is an important source of income especially for tutors and
other faculty members within training institutions. Vari-
ous compensation rates are in operation and a consultant
can earn more for one day's work than all their monthly
salary.
Providing services to their places of work
Some health workers are suppliers of goods and services
to their places of work. This privilege is mainly the
domain of persons in management and administration.
Such services include the provision of maintenance serv-
ices and selling stationary and other consumables to the
institution. Some health professionals either own firms or
are associated with vendors who are suppliers to the
organization. Some health professionals who may be
associated with suppliers get commissions for goods and
services provided to the organization. The existence of
pre-qualification for suppliers does not seem to reduce
this practice. One administrator said:
"It is mostly the accounts people that are into this. But the dis-
trict health office administrator can stop this. But you create
hatred if you do that."
Involvement is small to medium sized businesses
Hospital environments are suitable sites for small-scale
businesses such as selling soft drinks, doughnuts and
other groceries. Some health professionals engage in these
businesses as a means to earn extra income. Soft drinks
might be stored in hospital food refrigerators or Expanded
Program on Immunization (EPI) program or other hospi-
tal refrigerators and sold to patients, visitors and other
staff. A nurse reported:
"My children sell soft drinks at home when they have knocked
off from school. Since my house is close by, I can also keep an
eye on what is going on there."
Health professionals also reported engaging in various
other types of business not necessarily on health facility
grounds. These involved running a minibus service and
grocery shops.
Minimizing expenditure
In this category will be discussed what health profession-
als do in order to reduce expenses for their livelihoods.
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The general perception was that the cost of living was far
beyond the means of their salaries. Strategies for minimiz-
ing personal costs include:
a) Walking to work for some part or the whole trip, rather
than taking a bus
b) Sending children to public schools despite having neg-
ative attitudes towards these schools
c) Taking packed meals from home to eat at work or miss-
ing meals at work altogether
d) Using workplace resources for personal use e.g. use of
work phones for personal calls and vehicles for personal
errands.
Choosing to work to rural areas
According to the Ministry of Health and Population
Health Human Resources Plan, the majority of the health
professionals in Malawi worked in urban areas [14].
Despite the rural-urban difference, which would suggest
that the majority of health workers were in urban areas,
some do choose to work in rural areas where the cost of
living is perceived to be less than in urban areas. In rural
areas, there usually are institutional houses which civil
servants were given priority to rent. The rental charges are
much lower than the market value of the houses. This
privilege, although much more likely in the Ministry of
Health, is also available to other government depart-
ments. The MoH is only second to the Ministry of Educa-
tion in having its own accommodation which it rents to
its employees.
Perceptions of health professions towards survival
practices
There were mixed feelings towards the various survival
practices of health professionals in Malawi. These
depended on the nature of the survival practice and
whether individuals were assessing their own or another
persons practice when attitudes tended to be more nega-
tive. There was a general feeling of futility that there was
not much else the health professional could do to earn a
livelihood, and that the health system itself was responsi-
ble for the creation of an environment in which corrupt
practices were possible. However some health profession-
als expressed outright displeasure of practices that
involved inflation of prices, earning commission on the
purchase of hospital consumables, and the stealing and
selling of medicines meant to be supplied for free to
patients.
One expatriate administrator, commenting of reliance on
allowances said:
"This is something I have observed here in Malawi and it is sad.
But people get low salaries. Those that fund the health sector
must also realize that if workers continue to be poorly paid, they
(the workers) will find a way to supplement their salaries
through various means. In the end it makes sense just to pool
the resources for salaries and cheating will reduce."
Discussion
Health professionals in Malawi are facing the challenges
in their work in diverse ways ranging from being creative,
unethical and in some cases legally questionable ways.
One weakness of a qualitative study like this is the inabil-
ity to document the extent of the problem, and in some
cases, extremes may have preference to be reported.
The challenges faced by health professionals in Malawi
deserve concerted action. This calls for both multi-sectoral
and multi-pronged approaches involving the government,
training institutions, health workers themselves, health
worker associations/unions and the general public. Each
these groups have a stake in ensuring that health profes-
sionals remain in the country to provide much needed
health services.
The perceived discriminatory attitude against nurses
stands out an area that may benefit from policy change.
Currently, nurses can not become a district health officer
(DHO) and are rarely appointed health center in-charge.
The role of the DHO is mainly to provide leadership for
all health programs in a district and is the chief adminis-
trator of these programs. The DHO is supported by per-
sons trained in human resources management, accounts
and administration. It is doubtful that a medical doctor is
the only person who may posses the necessary skills and
training for such roles. Even when this may have been cth
case, that a clinical officer or medical assistant can be put
to head or district or a health center when a degree nurse
is available can not be justified. This is not in any way to
demean the contribution of clinical officers and medical
assistants, but rather to indicate that many nurses may be
more qualified before the responsibilities are put on clin-
ical officers and medical assistants.
The limited opportunities for supervision and over-
whelming responsibilities shouldered by health profes-
sionals are crucial challenges in respect of human
resources management. This could stem from the fact that
human resources and in general, resource management
does not feature significantly in the curricula of health
worker training in Malawi. And yet, human resource man-
agers may be these same health professionals with limited
knowledge and skills about human resources. There are at
least three options. Firstly, fully training human resources,
non-health professional, could be hired to provide the
necessary management of personnel. An alternative is to
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provide special training in human resources management
to health professionals identified to manage staff. Finally,
resources, including human resources management could
be incorporated in the curricula of health professionals'
training.
Malawi is implementing a decentralized health service. In
part, this meant that regional health offices, each respon-
sible for one of the three administrative regions of the
country, were abolished. The thinking then was that the
Ministry of Health headquarters would deal directly with
districts. While this resulted in reduction of administrative
bottlenecks, it also meant that supervision of the district
was no longer done by the regions (which had been abol-
ished), but rather the central office. It was later realized
that there was just not enough human resources from the
central office to carry out meaningful and regular supervi-
sion of the districts. As from 2004, the Ministry of Health
created supervisory zonal offices that will be responsible
for supervision of districts.
Supervision can not wait for zonal staff. Each level of serv-
ice will need to have internal supervision and receive visits
from the next hire level. The shortage of human resources
and rationing of resources (transport, time) will continue
to pose challenges to this need. It is of note however, that
the National Tuberculosis Program has institute a formi-
dable supervisory effort that is a model to other countries
[23-25].
Many young doctors in Malawi aim to obtain post-gradu-
ate qualifications [26,27]. Until 2003, there were no local
training programs and all post-graduate long-term spe-
cialist education for medical doctors was obtained
abroad. Access was limited. Starting from 2003 however,
it is possible to enroll in postgraduate course for medical
doctors and nurses within Malawi. This has potential to
encourage many deserving nurses and medical doctors to
remain in Malawi. The downside of this progress is that
some nurses and medical doctors will be better positioned
to find opportunities abroad after obtaining higher quali-
fications. Participants reported that in some cases where a
vacancy exists, recruitment methods are less transparent.
This can be changed by requiring that all public sector
jobs are advertised in the popular media and oversight by
health professionals' associations is made. There may also
be a complaints body that could have powers to investi-
gate claims of wrong doing in recruitment of health pro-
fessionals without victimizing the complainant.
Muula [28] has suggested that dual job-holding can, if
properly administered, benefit both patients and health
professionals. There is need to study how the current sys-
tem is functioning in order to suggest how regulation can
occur.
Some of the survival mechanisms such as stealing drugs
and getting a double salary when one is doing one job and
seeking payment for services that ought to be at no cost to
patients are outright unethical. The relevant professional
regulatory bodies need to strengthen their oversight role,
and the law enforcement agencies ought to be involved in
curbing these practices.
While many policy measures may be suggested for imple-
mentation, actual implementation is unlikely to occur at
the same time. There is need to prioritize which policy
measures need urgent attention, which ones may be
implemented when more information is obtained and
which one's may have limited impact.
The impact of HIV/AIDS on human resources is huge
especially in heavily burdened countries such as Malawi.
The World Health Report 2006 reports that death is the
most common cause of attrition for health workers in
Malawi [29]. While antiretrovirals are currently available
for free in Malawi, there is need to increase accessibility.
Just because the general public has access to HIV treat-
ment does not mean that health professional who is also
affected by being HIV infected themselves is accessing the
service.
From April 2005, the Malawi government has instituted a
salary supplementation to all health professionals work-
ing in the public sector. As a group, health professionals
within the public sector are earning more than any other
government employee on regular remuneration. It
remains to be seen as to whether this initiative with slow
down and reduce the out-migration of Malawian health
worker to northern countries.
Conclusion
The interest in the reasons behind health professionals'
migration from developing to developed nation has
sometimes led to researchers overlooking how those that
have remained (in the developing nation) earn their liv-
ing. We have reported that health professionals in Malawi,
though facing significant challenges, are doing all they can
to still make a living within a constrained environment.
The current situation where health professionals in the
public/civil service earn more than other workers proba-
bly will go a long way in sending the message that health
professionals are valued in Malawi.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
ASM conceived the study, designed the survey instru-
ments, supervised data collection and contributed to data
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analysis, drafted manuscript and approved final copy of
manuscript. FCM contributed to design of survey instru-
ments, collected data, contributed to data analysis and
critical review of manuscripts draft and approved the final
draft.
Appendix 1: Interview guide for health workers
The research assistant (RA) is required to introduce them-
selves and the purpose of the visit. After this, the RA
should obtain verbal consent. If the health worker
chooses not to participate, kindly thank the person and
move on to the next health worker that is lined up for
interviews.
1. What challenges do health workers face in this country?
2. How could (name each of the challenges suggested) be
solved?
3. Could you describe for me the various sources of
income that you have?
4. Is there anything else that you do from which you
obtain money or goods?
5. What else apart from those that you have mentioned?
6. How do some of the health workers that you have
known obtain income?
7. Let us start with your sources of income, how do you
perceive such methods? Do you like them or you have
some reservations?
8. Probe more on the perceptions of the methods by the
health workers?
9. How do you think other people perceive such kind of
income or resource generation?
10. The issue of loss of health staff has attracted public
attention. Why do you think health workers eventually
leave the country?
11. What do you think must be done in order to make
health workers remain in the country? What must be done
to enable health workers to remain at their place of work?
12. What is already being done in order to retain health
workers?
13. What must the government do to enable retention of
health workers?
14. What should the health workers themselves do to
ensure that health workers remain in the country?
Appendix 2: Interview guide for administrators
and policy makers
The research assistant (RA) is required to introduce them-
selves and the purpose of the visit. After this, the RA
should obtain verbal consent. If the administrator/policy
maker chooses not to participate, kindly thank the person
and move on to the next appointment that is lined up.
1. Could you tell me the challenges that health workers
are facing in Malawi
2. What other challenges do the health workers meet?
3. If the participate has not mentioned some of the follow-
ing (shortage of health workers, shortage of hospital sup-
plies, lack of promotion or clear career path, increased
work load, HIV and AIDS, infection risk, low remunera-
tion), please suggest and obtain a response whether these
are perceived by the respondent as notable challenges.
4. How could these challenges (name each of the sug-
gested challenges) be dealt with?
5. What is the government dealing with these challenges?
6. What is your perception of the brain drain phenome-
non?
7. Why are health workers leaving Malawi to work else-
where?
8. What is being done to reduce the brain drain?
9. What must be done to stem the drain of health person-
nel?
10. What is your perception of these measures? If question
seems not clear to respondent, ask what is his or her eval-
uation. Will the measures work, not work, easy to imple-
ment or difficult to implement? What may pose as
challenges in the implementation of the measures.
11. Despite the fact that health workers receive poor
remuneration, how are they then surviving?
12. What is you perception on (name a way of earning
income e.g. over-time)
13. What policy frameworks are available to address the
human resources shortages (and brain drain) in Malawi?
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BMC Health Services Research 2006, 6:97 http://www.biomedcentral.com/1472-6963/6/97
Page 12 of 12
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14. What is your assessment of this (name the policy)?
Will it be able to deliver the desired goal? What challenges
do you think presently exist? What challenges do you
think the future will present?
Acknowledgements
This work was funded by the Swedish Development Agency through the
Regional Network for Equity in Health in East and Southern Africa (EQUI-
NET) and Health Systems Trust (HST) of South Africa to the University of
Malawi, College of Medicine. A project report has been submitted to EQUI-
NET and HST. We also that the reviewers Leana Uys and Joses Kirigia
whose comments we will continue to value. Dr. Rene Loewenson (EQUI-
NET), Ms Antoinette Ntuli (Health Systems Trust-South Africa) and Mike
Rowson (MEDACT-UK) commented on an earlier draft of the manuscript.
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Pre-publication history
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... There have been a few reports of informal payments in healthcare in Malawi [18], however, a review on the subject shows that literature is limited, hence the need to do a study on informal payments in the public hospitals. Very few studies offer a glimpse into the existence of informal payments in healthcare in Malawi, but have not documented the magnitude of the problem. ...
... Very few studies offer a glimpse into the existence of informal payments in healthcare in Malawi, but have not documented the magnitude of the problem. One of the studies found that due to low salaries health workers are tempted to get gifts or demand payment from patients for a service [18]. Patients are sometimes pressured to pay for services provided at the public health facility, which are officially provided for free so that they are attended to faster or get a better service [2]. ...
Preprint
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Background: Informal payments in public health facilities act as a barrier to accessing quality healthcare services especially for the poor people. There is growing evidence that in most low-income countries, most poor people are unable to access quality health care services due to demands for payments for services that should be accessed for free. This research was aimed at investigating informal payments for health care services at Kamuzu Central Hospital, one of the referral public hospitals in Malawi. Results of this study provide evidence on the magnitude and factors influencing informal payments in Malawi so that relevant policies and strategies may be made to address this problem. Methods: The study employed a mixed methods research design. The quantitative study component had a sample size of 295 patients and guardians at Kamuzu Central Hospital (KCH). The qualitative study included 7 in-depth interviews with key informants (health workers) and 3 focus group discussions with guardians. Each FGD had 10 people. Thus, in total the whole qualitative sample constituted 52 participants. Quantitative data was analyzed using Excel and STATA. Qualitative data was analyzed using thematic content analysis approach. Results: 80% of patients and guardians at KCH had knowledge of informal payments. About 47% of the respondents admitted paying informally to access health care services at KCH and 87% of the informal payments were made at the request of a health worker. The study identifies lack of knowledge, fear and desperation by patients and guardians, low salary for health workers and lack of effective disciplinary measures as some of the key factors influencing informal payments in the public health sector in Malawi. Conclusion: Informal payments exacerbate inequality in the access of health care services that should be provided for free. Specifically, poor people have limited access to quality health care services when informal payments are demanded. This practice is unethical and it infringes on people’s rights to universal access to health care. There is need to strengthen the public health care system in Malawi by formulating deliberate policies that will deter informal payments.
... In Malawi, and other countries in the SSA region, allowances from sponsored training programmes are for many a substantial part of a monthly take-home salary, and can influence their overall pay satisfaction. 38 Findings from this study suggest that surgery as a profession is not regarded as highly as other medical specialties, specifically in regards to concerns over lack of opportunity to access other sources of income specific to the surgical discipline, namely 'training' and 'workshops. ' Respondents suggested that other specialities such as paediatrics offer greater opportunities to top-up a government salary through participation in such aforementioned activities and generally perceived as more 'profitable. ...
... 47 The barrier of perceived stagnancy and lack of clarity around the NPC career path within surgery is an issue reported in other studies based in Malawi on a range of health-workers, and in other countries. 36,38,48,49 According to the Lancet Commission on Global Surgery, defining and developing career pathways for mid-level cadres is essential for successful retention. 10 However, the lack of career structure for NPCs has resulted in the widespread perception that, at least in Malawi, they are trained to a level at which they are useful, and then abandoned. ...
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Title: Social Risk Management Strategies and Health Risk Exposure – Insights and Evidence from Ghana and Malawi. // Abstract: Risk exposure is a major cause of poverty, deprivation and persistent vulnerability worldwide. This volume analyzes individuals' and households' responses to a variety of risks, with an emphasis on health risks. The study adapts the Social Risk Management (SRM) conceptual framework and extends it considerably for academic inquiry. Using household data from Ghana and Malawi, empirical evidence is provided on the complex relationship between high risk exposure and the application of proactive and reactive SRM strategies (incl. health insurance), showing their specific contributions to risk management. // The PhD thesis has been published as monography in the series "Social Protection in Health - Challenges, Needs and Solutions in International Health Care Financing" at LIT-publisher. URL: http://lit-verlag.de/isbn/3-643-90642-7 // Die Dissertation ist als Monographie in der Reihe "Social Protection in Health - Challenges, Needs and Solutions in International Health Care Financing" des LIT-Verlages erschienen. URL: http://lit-verlag.de/isbn/3-643-90642-7
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Background Maternal mortality in East Africa is high with a maternal mortality rate (MMR) of 428/100,000 live births. Malawi, whilst comparing favourably to East Africa as a whole, continues to have a high MMR (349) despite it being reduced by 53% since 2000. To make further improvements it is vital that initiatives are carefully targeted and evaluated to achieve maximum impact. The Malawian Government is committed to improving maternal health, however, to achieve this, it is vital that quality of care is high, this requires enough staff with appropriate training. There are not enough midwives in Malawi, therefore, focussing on staff working lives has the potential to improve care and retain staff within the system. Objectives to identify ways in which working lives of maternity healthcare workers could be enhanced to improve clinical care. Study Design An ethnographic study of three district level hospitals in Malawi over one year. Data was collected through observations and discussions with staff and analysed iteratively. The ethnography focussed on the inter-relationships between staff as these relationships seemed most important to working lives. The field jottings were transcribed into electronic documents and analysed using NviVo. Findings were discussed and developed with the research team, participants and other researchers and healthcare workers in Malawi. To understand the data we developed a conceptual model ‘the social order of the hospital’ using political sociologist Bourdieu's work. The social order was made up of the social structure of the hospital (hierarchy), the rules of the hospital (how staff in different staff-groups behaved) and the precedent (following the example of those before them). Results We used the social order to consider the different core areas that emerged from the data: processes, clinical care, relationships and context. The Malawian system is under-resourced with staff unable to provide high-quality care due to lack of infrastructure and equipment. However, there are also processes which hinder them on a national and local level for example staff rotations through to poorly managed processes for labelling drugs. Staff are aware of the clinical care they should provide, however sometimes don't provide it because they are working with the pre-defined system and they do not want to disrupt it. Within all of this there are hierarchical relationships and a desire to move to the next level of the system to ensure a better life with more benefits and less direct clinical work. These elements interact to keep care at its most basic as disruption to the ‘usual’ way of doing things is challenging and creates more work. Conclusions To improve the working lives of Malawian maternity staff it is necessary to focus on improving the working culture, relationships and environment. This may help the next generation of Malawian maternity staff to be happier at work and better able to provide respectful, comprehensive, high-quality care to women.
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Chapter
It is now more than a decade since the acknowledgement of the health human resources crisis that exists in many low-income countries. During that decade much attention has focused on addressing the “pull” factors (e.g. developing voluntary international recruitment guidelines and bilateral agreements between recruiting and source countries) and on scaling up the supply of health professionals. Drawing on research conducted in two sub-Saharan African countries, we argue that a critical element in the human resources crisis is the poor working environments in these countries that not only continue to act as a strong “push” factor, but also impact on the motivation and performance of those who remain in their home countries. Unless attention is focused on improving work environments, the human resources crisis will continue in a vicious cycle leading to further decline in the health systems of low-income countries.
Chapter
It is now more than a decade since the acknowledgement of the health human resources crisis that exists in many low-income countries. During that decade much attention has focused on addressing the “pull” factors (e.g. developing voluntary international recruitment guidelines and bilateral agreements between recruiting and source countries) and on scaling up the supply of health professionals. Drawing on research conducted in two sub-Saharan African countries, we argue that a critical element in the human resources crisis is the poor working environments in these countries that not only continue to act as a strong “push” factor, but also impact on the motivation and performance of those who remain in their home countries. Unless attention is focused on improving work environments, the human resources crisis will continue in a vicious cycle leading to further decline in the health systems of low-income countries.
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Objective: To explore the type of private practice supplementary income-generating activities of public sector doctors in the Portuguese-speaking African countries, and also to discover the motivations and the reasons why doctors have not made a complete move out of public service. Design: cross-sectional qualitative survey. Subjects: In 1996, 28 Angolan doctors, 26 from Guinea-Bissau, 11 from Mozambique and three from S Tome and Principe answered a self-administered questionnaire. Results: All doctors, except one unemployed, were government employees. Forty-three of the 68 doctors that answered the questionnaire reported an income-generating activity other than the one reported as principal. Of all the activities mentioned, the ones of major economic importance were: public sector medical care, private medical care, commercial activities, agricultural activities and university teaching. The two outstanding reasons why they engage in their various side-activities are 'to meet the cost of living' and 'to support the extended family'. Public sector salaries are supplemented by private practice. Interviewees estimated the time a family could survive on their public sector salary at seven days (median value). The public sector salary still provides most of the interviewees income (median 55%) for the rural doctors, but has become marginal for those in the urban areas (median 10%). For the latter, private practice has become of paramount importance (median 65%). For 26 respondents, the median equivalent of one month's public sector salary could be generated by seven hours of private practice. Nevertheless, being a civil servant was important in terms of job security, and credibility as a doctor. The social contacts and public service gave access to power centres and resources, through which other coping strategies could be developed. The expectations regarding the professional future and regarding the health systems future were related mostly to health personnel issues. Conclusion: The variable response rate per question reflects some resistance to discuss some of the issues, particularly those related to income. Nevertheless, these studies may provide an indication of what is happening in professional medical circles in response to the inability of the public sector to sustain a credible system of health care delivery. There can be no doubt that for these doctors the notion of a doctor as a full-time civil-servant is a thing of the past. Switching between public and private is now a fact of life.
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To explore the type of private practice supplementary income-generating activities of public sector doctors in the Portuguese-speaking African countries, and also to discover the motivations and the reasons why doctors have not made a complete move out of public service. Cross-sectional qualitative survey. In 1996, 28 Angolan doctors, 26 from Guinea-Bissau, 11 from Mozambique and three from S Tomé and Principe answered a self-administered questionnaire. All doctors, except one unemployed, were government employees. Forty-three of the 68 doctors that answered the questionnaire reported an income-generating activity other than the one reported as principal. Of all the activities mentioned, the ones of major economic importance were: public sector medical care, private medical care, commercial activities, agricultural activities and university teaching. The two outstanding reasons why they engage in their various side-activities are 'to meet the cost of living' and 'to support the extended family'. Public sector salaries are supplemented by private practice. Interviewees estimated the time a family could survive on their public sector salary at seven days (median value). The public sector salary still provides most of the interviewees income (median 55%) for the rural doctors, but has become marginal for those in the urban areas (median 10%). For the latter, private practice has become of paramount importance (median 65%). For 26 respondents, the median equivalent of one month's public sector salary could be generated by seven hours of private practice. Nevertheless, being a civil servant was important in terms of job security, and credibility as a doctor. The social contacts and public service gave access to power centres and resources, through which other coping strategies could be developed. The expectations regarding the professional future and regarding the health systems future were related mostly to health personnel issues. The variable response rate per question reflects some resistance to discuss some of the issues, particularly those related to income. Nevertheless, these studies may provide an indication of what is happening in professional medical circles in response to the inability of the public sector to sustain a credible system of health care delivery. There can be no doubt that for these doctors the notion of a doctor as a full-time civil-servant is a thing of the past. Switching between public and private is now a fact of life.
Article
The global targets for tuberculosis (TB) control were postponed from 2000 to 2005, but on current evidence a further postponement may be necessary. Of the constraints preventing these targets being met, the primary one appears to be the lack of adequately trained and qualified staff. This paper outlines: 1) the human resources and skills for global TB and human immunodeficiency virus (HIV) TB control, including the human resources for implementing the DOTS strategy, the additional human resources for implementing joint HIV-TB control strategies and what is known about human resource gaps at global level; 2) the attempts to quantify human resource gaps by focusing on a small country in sub-Saharan Africa, Malawi; and 3) the main constraints to human resources and their possible solutions, under six main headings: human resource planning; production of human resources; distribution of the workforce; motivation and staff retention; quality of existing staff; and the effect of HIV/AIDS. We recommend an urgent shift in thinking about the human resource paradigm, and exhort international policy makers and the donor community to make a concerted effort to bridge the current gaps by investing for real change.
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Background: The United Kingdom and the United States are among several developed countries currently experiencing nursing shortages. While the USA has not yet implemented policies to encourage nurse immigration, nursing shortages will likely result in the growth of foreign nurse immigration to the USA. Understanding the factors that drive the migration of nurses is critical as the USA exerts more pull on the foreign nurse workforce. Aim: To predict the international migration of nurses to the UK using widely available data on country characteristics. Method: The Nursing and Midwifery Council serves as the source of data on foreign nurse registrations in the UK between 1998 and 2002. We develop and test a regression model that predicts the number of foreign nurse registrants in the UK based on source country characteristics. We collect country-level data from sources such as the World Bank and the World Health Organization. Results: The shortage of nurses in the UK has been accompanied by massive and disproportionate growth in the number of foreign nurses from poor countries. Low-income, English-speaking countries that engage in high levels of bilateral trade experience greater losses of nurses to the UK. Conclusion: Poor countries seeking economic growth through international trade expose themselves to the emigration of skilled labour. This tendency is currently exacerbated by nursing shortages in developed countries. Countries at risk for nurse emigration should adjust health sector planning to account for expected losses in personnel. Moreover, policy makers in host countries should address the impact of recruitment on source country health service delivery.
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The College of Medicine of the University of Malawi was opened in April 1991. Over almost a decade it has flourished in the face of economic and political constraints, as well as a change in the philosophy of donor support. We review the past, assess the present and look to the future.
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High death rates are reported in health care workers (HCWs) and teachers in urban areas of Malawi. The present study was carried out to determine the annual death rate in HCWs and primary school teachers working in semi-urban and rural areas of Malawi, and to try to ascertain the main causes of death. Forty district and mission hospitals in Malawi were visited. A record was made of the number of clinical and nursing-based HCWs in each hospital in 1999, the number of deaths in that calendar year and reported causes of death. A record was also made of the number of teachers working in 4 primary schools nearest to each hospital in 1999, the number of deaths in that calendar year and reported causes of death. There were 2979 HCWs, of whom 60 (2.0%) died. There were 4367 teachers of whom 101 (2.3%) died. Annual death rates, calculated per 100,000 people, were significantly higher in male HCWs compared with female HCWs (2495 versus 1770, RR 1.17, 95% CI 1.14-1.20, P < 0.001), and significantly higher in female teachers compared with male teachers (2521 versus 1934, RR 1.14, 95% CI 1.11-1.17, P < 0.001). In male HCWs and teachers the highest death rates were in those aged 35-44 years. In female HCWs and teachers, the highest death rates were in those aged 25-34 years and 35-44 years, respectively. Reported causes of death in HCWs were tuberculosis (TB) in 47%, chronic illness in 45% and acute illness in the remainder, while in teachers the causes were TB in 27%, chronic illness in 49% and acute illness in 25%. Chronic illness, thought to be due to AIDS, and TB were the common causes of death. The current high death rates from AIDS and TB will have a crippling toll on the health and education sectors, and effective ways of reducing these death rates must be found.
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Access to basic health services was affirmed as a fundamental human right in the Declaration of Alma-Ata in 1978. The model formally adopted for providing healthcare services was "primary health care" (PHC), which involved universal, community-based preventive and curative services, with substantial community involvement. PHC did not achieve its goals for several reasons, including the refusal of experts and politicians in developed countries to accept the principle that communities should plan and implement their own healthcare services. Changes in economic philosophy led to the replacement of PHC by "Health Sector Reform", based on market forces and the economic benefits of better health. It is time to abandon economic ideology and determine the methods that will provide access to basic healthcare services for all people.