Various themes emerged from the interviews and the literature searches on the retention and survival mechanisms of health professionals in Malawi. In general, the following themes were identified; challenges faced health professionals, survival strategies and perceptions towards the survival strategies. The sub-themes under challenges faced included; inequitable salaries and recognition of experience, overwhelming responsibilities, lack of stimulating interaction in the workplace, inadequate supervision, impact of HIV and AIDS, limited access to further training, limited career recognition, lack of transparency in recruitment of staff, and discriminatory remuneration. The sub-themes under survival strategies included ways of minimizing 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 officers (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 completing their internships are posted as DHOs. This however 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 privileges. 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 supplementation 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 privileges.
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 assistants. 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 medical assistant (MA) could be sent to a health centre and be in charge of that health center, responsible for all the supplies 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 certificate."
Situations like those stated above were reported to be sources of frustration and resentment towards the health care system.
Health professionals in Malawi reported finding themselves 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 continue 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.
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 invitations to workshops, seminars and conferences, and therefore 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 laboratory 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 frustration because of the lack of professional interaction. The lack of academically and professionally challenging environment was exacerbated by the absence of any requirement 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 updating one's skill in order for re-registration by the regulatory and professional bodies to occur. As there was requirement for continued professional development as a necessity for re-registration by the regulatory bodies, health workers felt there were not being "pushed" to maintain excellence.
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 commitments and responsibilities prevented them from making 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 supervision. 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 professionals 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 . Although the Health Sector Human Resources Plan did not indicate the distribution of causes of deaths among the various health cadres, 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% . Tuberculosis infection rates among health workers in Malawi are higher than the general community . 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 altogether.
Limited access to further training
Many health professionals valued access to further training. Employment as a junior faculty member within a university 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 institution. Sponsoring agencies and government are more likely to support postgraduate training for a university employee than for a health professional working in a non-educational institution. This offered as an attraction for employment 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 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 occurring 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, impeding 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 specialties of Internal Medicine, Surgery, Obstetrics and Gynaecology and Surgery. Graduate public health training was started much earlier in 2003 . Currently however this training in the clinical specialist programs is only available 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. However, 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 assisting in the retention of health professionals. However, when a health professional has acquired additional qualifications, 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 professional may leave. Several medical doctors obtained post-graduate qualifications abroad in Public Health/Epidemiology. 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 recognition for its staff since it can only promote its staff to P5 grade, a level already attained by several DHOs. Promotions 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 financial 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 recruitment 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-motivating. Many just remain in the public service in order to gain work experience before moving on .
Respondents indicated that one area that they find frustrating is in receiving much lower remuneration packages than expatriate technical support staff who in some cases may have the same or even a lesser qualification and experience. 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 personal 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 categories i.e. increasing income and minimizing expenditure.
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 sector are also involved in farming. Some health professionals, 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 districts 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.
It is often reported that significant quantities of drugs supplied 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 stealing drugs and selling them to drug vendors or private clinics . Some pharmacy assistants and technicians in particular are reported to be heavily involved. This practice has been reported in many other African countries .
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 themselves. 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 medicines, 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 . These authors reported that at workshop by the MoH, the Minster mentioned about the issue but did not address the matter significantly although the MoH was aware of which health professionals 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 opportunity 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 property 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 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 institutional vehicle and institutional fuel, the health professional 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 reimbursement 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 allowances."
It was also reported that when workshops are being conducted 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 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 hospital 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) regulations. Although the MCM requires that a health professional 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 practice 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 interests 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 transfer 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 otherwise 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 consultations and clinical reviews.
Double salaries and supplementation
Almost all health professionals are guaranteed employment 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 sector 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 transferred 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 station. 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 salary supplements from donors who are unaware that a worker is already in receipt of another supplement.
Skilled health professionals are able to undertake consultancy 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. Various 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 services 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 district 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 hospital 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.
In this category will be discussed what health professionals do in order to reduce expenses for their livelihoods.
The general perception was that the cost of living was far beyond the means of their salaries. Strategies for minimizing personal costs include:
Walking to work for some part or the whole trip, rather than taking a bus
Sending children to public schools despite having negative attitudes towards these schools
Taking packed meals from home to eat at work or missing meals at work altogether
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 . 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 departments. The MoH is only second to the Ministry of Education 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 negative. 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 responsible for the creation of an environment in which corrupt practices were possible. However some health professionals 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."