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

Malawi is one ofAfrica’s poorest countries. Although its health infrastructure is fairly welldeveloped, this is in very poor condition. The public health sector has battleda rising demand for services caused by population growth and a high HIV andAIDS 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 theMalawian government declared the human resources shortage a crisis. TheMinistry of Health launched an Essential Health Package initiative to tacklethe 11 main causes of death and illness. Donors responded to the crisis byhelping the country develop a complementary Emergency Human ResourcesProgramme. A study by the UK Department for International Development's Malawioffice examined this human resources crisis. It assessed progress made within ayear of implementation of the programme in April2005.

The study foundthat:

• Salary top-ups introduced to improvestaff recruitment and retention helped reduce the flow of staff,especially nurses, from the public sector.
• Good progress had been made with therecruitment and re-engagement drive, with 591 staff recruited externallyby the end of 2005 and over 1,100 promoted internally.
• The recruitment of stop-gap expatriatesupport included 19 people in place and the deployment shortly of afurther 51 doctors and 15 nurse tutors.
• Of the 1,000 Malawian healthprofessionals who had left the public sector, 700 were willing to returndue to top-ups, more flexible deployment and further training.
• However, overseas migration of themost senior and experienced nurses continued in 2005.

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

• After it was shown that insufficienthuman resources prevented the success of donor-funded projects, two donorsagreed to a comprehensive, outcomes-based approach for Malawi thatincluded tackling staffing. Other African countries could also benefit fromthis approach.
• The improvement of working conditionsand management practices is as important as pay when it comes to improvingstaff morale and retention.
• It is important to combine bothshort-term and long-term measures to ensure commitment to the programme.Salary top-ups, for instance, had an immediate effect.
• This case illustrates the importanceof management of industrial relations.
• Malawi, and other African countries,will need to produce an excess of nurses to account for the ongoingmigration of nurses overseas, and to track these trends.