Tackling Malawi's medical brain drain
ince the turn of the century, global migration has grown hugely. However, the past decade has seen developing countries losing large numbers of health care professionals to developed countries. The voluntary migration of health workers from developing to developed countries diminishes health systems in low-income countries. It also threatens the achievement of the health-related Sustainable Development Goals.
Malawi now faces severe staffing shortages in the health sector and high migration of health workers. Some estimates show that Malawi trains 60 nurses a year, but loses around 100, with more than half of them going to the United Kingdom. Yet the country also had vacancies in all nursing and clinical cadres, with a horrific 75 percent vacancy rate for nurses. Only 28 percent of targeted clinical officers and 40 percent of targeted nurse midwife cadres were filled, yet they carry out the bulk of emergency obstetric care.
Changes in political and economic developments in the region in the past two decades have also affected the destination and composition of the stock of Malawian emigrants. In 1990, half of all Malawian emigrants lived in Zimbabwe, followed at some distance by Zambia (14 percent) and South Africa (11 percent). However, with the cessation of hostilities in Mozambique and the economic difficulties in Zimbabwe, the share of Malawian emigrants to Mozambique rose from 2 percent in 1990 to 20 percent by 2000 and to 25 percent by 2015 — and the share of emigrants to Zimbabwe fell from 56 percent in 1990 to 34 percent in 2015.
Migration of Health Workers from Malawi
Until 1991, Malawian doctors who emigrated were almost entirely those who stayed in OECD (Organisation for Economic Co-operation and Development) countries after their training. The creation of Malawi's first medical school coincided with the political liberalisation and economic turmoil of the 1990s. As soon as Malawi began locally training doctors, the nature of migration changed, but results remained the same. Two hypotheses. First, the first three years of training for the first cohorts of medical students in Australia and the UK may have reinforced an affinity for foreign medical traditions and the desire to work abroad after qualification. Second, due to a lack of postgraduate training facilities in Malawi, the historical legacy of using medical training as a self-empowerment tool persists because Malawian doctors still go abroad for specialist training.
In contrast, the migration of nurses became notable only after the collapse of the one-party regime in the early 1990s. Before 1993, Malawi still controlled the movement of people, and all civil servants needed government clearance to go abroad, even on holiday. Then, during the transition to democracy, the new government could not keep up with aggressive recruitment drives for nurses by UK recruiters. Local training of doctors and upgrading of nurses sharply increased the output of health workers, but it was less effective as a scheme to retain skilled workers. Coupled with the low number of graduates from the country's only medical school, emigration tightened staff shortages.
In 2004, Malawi had 1.1 doctors and 25.5 nurses for every 100 000 people — so the entire country had only about 250 doctors. In comparison, neighbouring Tanzania had 2.3 doctors and 36.6 nurses per 100 000 population in 2004, while the regional density in Africa was 22 doctors and 90 nurses per 100 000 population. Such a low density of health workers impaired the coverage and quality of health services.
Emergency Human Resources Programme
In 2004, the government declared a “human resource crisis” in the health sector and launched a six-year Emergency Human Resources Programme (EHRP) the next year. At the time, Malawi had the lowest doctor staffing levels in Southern Africa and few Malawian-born specialists, with most specialist posts running at 80–90 percent vacancy rates and many positions filled by expatriate doctors. In addition, the disparity in the staff distribution was huge between urban and rural areas. Although more than 80 percent of Malawi's people reside in rural areas, half of Malawi's doctors worked in central hospitals, and an astounding 16 of 23 district hospitals did not have a single doctor. The EHRP stemmed the outflows, especially of nurses, and increased the output from training institutions. Graduates from Malawi's four main health training institutions rose from 917 in 2004 to 1 277 in 2009. Physician graduates from the College of Medicine increased from 18 in 2004 to 31 in 2009, as the annual output of clinical officers doubled and that of laboratory technicians quintupled to 131. At the same time, the migration of nurses declined.
Although the creation of the Kamuzu College of Nursing and the School of Medicine increased production of nurses and doctors, the limited number of graduates cannot meet Malawi's capacity challenges, leaving Malawi still dependent on foreign medical expertise and volunteers. While local training of doctors and expanding nurses' training partially alleviates capacity deficits, both have had less effect as retention schemes. Locally trained doctors are just as likely to migrate as foreign-trained doctors. The EHRP demonstrated that targeted incentive schemes can retain skilled health workers, especially for lower cadres of health workers. But it requires huge technical and financial assistance from donors.
"The EHRP demonstrated that targeted incentive schemes can retain skilled health workers, especially for lower cadres of health workers. But it requires huge technical and financial assistance from donors."
Prospects for Brain Circulation through Short-term Cyclical Migration
The potential to physically tap into the pool of diaspora resources depends on the repertoire of skills among the diaspora and on the strength of ties that the diaspora has with the homeland. On leaving Malawi, about 80 percent of emigrants were employed and the other 20 percent were either unemployed or below employment age. For the employed, the single largest category was public services (academia, civil servants, and public service—49 percent), followed by those in the private sector (30 percent). There is no record that Malawi has made any serious effort or formulated any initiatives to tap into the diaspora as a source of any type of capital. Nor has the diaspora participated in initiatives to transfer skills physically, virtually or through mentoring. Of six PhDs and 20 Master's degree holders, only two people said they had been involved physically in a skills transfer programme while one participated in a virtual skills transfer (supervising a PhD thesis).
Half the respondents were not willing or not sure about returning to Malawi permanently, but two-thirds were willing to return on a short-term basis as part of a skills transfer programme. Among the latter, 46 percent were willing to return for at most one month, 30 percent for one to two months and 17 percent for three to six months. Seven of the Malawians willing to come on a short-term basis had served as short-term technical experts in a dozen countries across Africa.
Over half the respondents who expressed willingness to return permanently indicated that although “the heart was willing” they saw several barriers to their return. The main barrier was economic uncertainty (lack of a foreseeable source of livelihood in Malawi) followed by the need to maintain legal status, citizenship and visa requirements in the country of residence, and by political or legal restrictions.
In the short term, cyclical migration of skilled people — brain circulation — will require serious programming and resource mobilisation. Twenty-one of the 28 respondents willing to come on a skills programme expected some assistance from the government. The single largest requirement was a return air ticket, followed by accommodation and, to a lesser degree, medical insurance and local transport. Malawi does not have the capacity to monitor migration, skilled or otherwise, for the destination, demographics and skill profiles of its diaspora.
Diaspora programmes are insufficient for engaging Malawians living abroad. Lacking capacity in policy development, Malawi relied on the International Organization for Migration to develop its diaspora engagement programme. It now lacks the capacity for policy implementation, reflected in part in the government's inability fully resource the diaspora section in the Ministry of Foreign Affairs for full-scale implementation of the policy.
Key Recommendations for Malawi
The government of Malawi needs to expand its output from health training institutions by increasing the capacity of existing institutions and creating new ones, taking into account domestic needs and allowing for attrition through internal brain waste and migration.
To strengthen the commitment to serve Malawi, the government needs to ensure that medical students from the new private medical school have fair access to the publicly funded Universities Loan Scheme at comparable terms and conditions, including bonding and residency.
Relevant civil service commissions, the Department of Human Resources Development and Management, and training institutions should work with the Ministry of Finance to anticipate and provide seamless absorption from medical schools for graduates from health training institutions.
The government of Malawi should prioritise globally competitive or endangered professions and transparently adjust their remuneration, within a context of fair civil service salary structures (not alienating other professions).
To the extent that Malawi's human resources for health gaps persist, the government should negotiate a successor program for continuing intervention.
This is an extract from an occasional paper by our content partner, the African Capacity Building Foundation. Download the full publication here.
(Main image: Chris Jackson/Getty Images)