Tackling Malawi's medical brain drain

Since 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.