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Tackling the human resources crisis in Malawi’s public health system

Since the late 1990s, Malawi’s public health services have appeared to be heading for collapse due to declining staffing levels. The government launched the Essential Health Package in 2004 to help improve the health of the population, which includes scaling-up HIV and AIDS-related services. The biggest challenge facing the initiative is improving human resource levels.

The Commission for Macroeconomics and Health has highlighted how vital improved health is for economic growth and human development. As a result, the international focus has been on providing more cost-effective funding to improve health services and to strengthen national health systems. The link between staffing levels and improved health has been highlighted as the main ingredient that holds health systems together.

Malawi is one of Africa’s poorest countries. Although its health infrastructure is fairly well developed, this is in very poor condition. The public health sector has battled a rising demand for services caused by population growth and a high HIV and AIDS rate. Yet its health staffing levels, the lowest in sub-Saharan Africa, are not enough to maintain even a minimum level of care.

In 2004 the Malawian government declared the human resources shortage a crisis. The Ministry of Health launched an Essential Health Package initiative to tackle the 11 main causes of death and illness. Donors responded to the crisis by helping the country develop a complementary Emergency Human Resources Programme. A study by the UK Department for International Development's Malawi office examined this human resources crisis. It assessed progress made within a year of implementation of the programme in April 2005.

The study found that:

Salary top-ups introduced to improve staff recruitment and retention helped reduce the flow of staff, especially nurses, from the public sector.
Good progress had been made with the recruitment and re-engagement drive, with 591 staff recruited externally by the end of 2005 and over 1,100 promoted internally.
The recruitment of stop-gap expatriate support included 19 people in place and the deployment shortly of a further 51 doctors and 15 nurse tutors.
Of the 1,000 Malawian health professionals who had left the public sector, 700 were willing to return due to top-ups, more flexible deployment and further training.
However, overseas migration of the most senior and experienced nurses continued in 2005.

In the past, donors have been unwilling to contribute to salaries and incentive packages for staff, due to concerns about donor dependency and project sustainability. However, this new approach has been successful in Malawi and has provided a number of lessons:

After it was shown that insufficient human resources prevented the success of donor-funded projects, two donors agreed to a comprehensive, outcomes-based approach for Malawi that included tackling staffing. Other African countries could also benefit from this approach.
The improvement of working conditions and management practices is as important as pay when it comes to improving staff morale and retention.
It is important to combine both short-term and long-term measures to ensure commitment to the programme. Salary top-ups, for instance, had an immediate effect.
This case illustrates the importance of management of industrial relations.
Malawi, and other African countries, will need to produce an excess of nurses to account for the ongoing migration of nurses overseas, and to track these trends.

Source(s):
‘Tackling Malawi’s Human Resources Crisis’, Reproductive Health Matters 14(27), pages 27-39, by Debbie Palmer, 2006

id21 Research Highlight: 28 August 2007

Further Information:
Debbie Palmer

Contact the contributor: d-palmer@dfid.gov.uk

Department for International Development, UK

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