Overcoming Malawi's Crisis in Health Worker Shortages

Overcoming Malawi's Crisis in Health Worker Shortages

Blog post originally appeared on Global Health Magazine.

Six years ago the Malawi health system was on the verge of collapse due to severe shortages of health workers. Every year the College of Medicine would train 20 doctors and every year, half of them would leave the country. Nurses were overwhelmed by the demand for services.

Ratios of doctor and nurses to population were the lowest of all countries in Southern Africa. HIV & AIDS was on the rise and without more health staff, the roll-out of antiretroviral therapy (ART) would remain just a dream. Today, Malawi has increased its total health workforce by 53 percent. Physicians have increased from 43 in 2004 to 265 in 2009, a 516 percent increase. The number of nurses has risen by 39 percent. Graduates from Malawi's four main training institutions have also shown a similar overall increase, from 917 in 2004 to 1,277 in 2009.

More importantly, these achievements have resulted in health service improvements including out-patient services, child immunizations, ante-natal care, and safer deliveries for women. Malawi can also now point to an increase in people on ART from 13,000 to over 276,000. A recent evaluation by Management Sciences for Health (MSH) and Management Solutions Consulting estimates that, in total, an additional 13,000 were saved.

How did Malawi do this?

The government took decisive action to develop and implement one of the most far reaching and innovative emergency human resource strategies implemented in sub-Saharan Africa to date. With the assistance of donors, the Emergency Human Resource Program - or EHRP as it became known - focused primarily on increasing staffing levels through financial incentives and a massive scale-up of pre-service training. From the beginning, the program recognized that the first step was to stop the hemorrhaging of health workers out of the health sector.

It succeeded in doing this by ‘topping up' the salaries of 11 of the most critical cadres of health workers by 52 percent. It also planned two ‘galas' to recruit health workers back into the system and offered staff about to retire a 3-year contract to stay. The donors' willingness to support salary increases through the top-ups and the government's willingness to allow different pay scales was a key factor of success.

At the same time, Malawi's leaders recognized the need to dramatically increase the number of new health workers being trained. This expansion of pre-service training was, and is, a cornerstone of the program and a key factor in its success was the fact that the program paid student fees in exchange for a commitment from the students to serve for a period of five years. This enabled many more people who had not been able to afford the costs of training to enroll.

Recognizing that an increase in staff would require an increase in management capacity, the EHRP also enlisted the aid of technical advisors to improve the Human Resource Management System. Historically in Malawi, as in many other countries in sub-Saharan Africa, the human resource management system was plagued by delays in the recruitment and deployment of staff and little control over staff workload. As a result, motivation was at an all time low.

As a stop gap measure, the program relied on international volunteers, through the UNDP and the VSO to fill critical gaps in services. Not only did these clinical officers provide direct services, but they also trained local staff on implementing ART and other needed health services.

The success of the EHRP is impressive. As the Global Health Workforce Alliance commented, "this innovative program in Malawi demonstrates that progress is possible, and lives can be saved when political will, sound strategies and adequate resources come together."

Nonetheless, the work is not yet done. Now that the crisis has been stabilized, it is time to move from an ‘emergency' mode to a period of transition, building a fully staffed health system through a development phase that emphasizes strategic planning, systems strengthening, performance management and sustainable funding for the financial incentives.

While the human resources situation in many developing countries remains bleak, Malawi's experience provides a shining example of how other struggling countries can bolster their health workforce, given time, support and commitment. For development professionals working in human resources for health, it is a good example of how a comprehensive intervention can contribute toward progress on the health-related Millennium Development Goals. Now that the example has been set, donors and national governments must make a deeper commitment to develop, expand and support similar programs.

Mary O'Neil, EdD, is a principal program associate, Human Resources for Health at MSH.