Features of a good job: work preferences of Malawi’s nurses

Many developing countries suffer from critical shortages of trained health workers, but Malawi’s shortage is severe even by African standards.  With fewer than 4000 doctors, nurses and midwives to serve the population of 12 million, the country’s ability to provide health services is compromised. Measures to recruit and retain more staff are urgently needed.

In 2005 the Malawian governmentwith support from international donors, initiated a six-year programme toincrease the availability and retention of qualified health staff.  The Emergency Human Resource programme hasthree components: a 52 percent salary increase for health professionals,improved capacity at training institutions, and short term recruitment ofadditional foreign volunteer doctors and nursing tutors. 

This paper from the OverseasDevelopment Institute’s Economic and Statistical Analysis Unit reports on a studyregarding the employment preferences of public sector registered nurses inMalawi. Its findings have relevance for the design of incentives encouragingnurses to remain employed within the Malawi public sector health service.

The research method used was a discretechoice experiment, which is a quantitative technique derived from consumerpreference surveys. Six job attributes were identified through in-depthinterviews with public sector nurses: place of work, net salary, availabilityof resources, workload, housing provision and opportunities for further education.For each attribute a base level was set corresponding to existing workingconditions, with additional levels representing a reasonable improvement overthe base level. These were used to construct hypothetical job descriptions.Participants each considered fifteen pairs of job descriptions and were askedwhich they considered the best job, and which, given their currentcircumstances, they would choose.

Statistical analysis of theresponses revealed that:

• Theoverwhelming majority indicated that increased salaries would improve retentionof registered nurses in the public sector.
• Improvingthe availability of resources and opportunities to upgrade qualifications wouldalso increase retention.
• Notwithstandingthe preference for higher pay levels, all six of the attributes were found tohave a statistically significant effect on job satisfaction.
• Whilehousing provision was valued, no significant difference in satisfaction wasfound between provision of basic or superior levels of housing.
• Therewas a perception that the best jobs were located in cities, however, takinginto account their circumstances, both urban and rural respondents expressed apreference for jobs in district towns.

The findings show that nurses maybe willing to sacrifice increases in salary in favour of improvements in otheraspects of their working conditions. The Malawi government therefore hasaccess to a range of strategies to improve the value that registered nursesplace on their employment in the public sector. Recommendations for policyinclude:

• Thegovernment’s strategy of increasing pay levels is likely to have a positiveimpact on how registered nurses value their employment.
• Improvedpay was the single most important attribute identified that might improve jobsatisfaction, followed by opportunities for further education and the provisionof basic housing.
• Improvementsin the quality of housing provided would have little impact on how nurses valuetheir employment.
• Establishingthe relationship between pay increases and retention of registered nurses wouldrequire additional research.