Investing in the workforce: The Malamulo scholarship initiative to improve
retention of health workers in Thyolo District, a rural district in Malawi
Katharina Hermann¹, Amanda Banda¹, Joe Kalilangwe², Andrew Likaka², Carol Metcalf3, Edwin Nkhono², Paul Moyo4
¹ Médecins Sans Frontières, Thyolo, Malawi; ² Ministry of Health, Thyolo District, Malawi; 3 Médecins Sans Frontières, Cape Town, South Africa; 4 Malamulo College of Health Sciences, Thyolo, Malawi
Background
"When I was 15 years [old], my
sister fell sick and we took her to
Thekerani hospital. The queue
was so long and there was only
one clinician. We arrived at 7 am
and my sister died right there in
the queue at 2:00 pm, it was very
difficult to understand. The death
of my sister was due to the
shortage of health care workers
and I decided to become one."
• Malawi has 2.3 doctors and 36.8 nurses per 100,000 population, considerably
below World Health Organization (WHO) recommendations (Table 1)
Table 1: Health workers per 100,000 population
Malawi (2009) Thyolo District (2010) WHO recommendations
Doctors
2.3
0.3
20
Nurses
36.8
16.0
100
• Urban: rural imbalance: 30% of the health care workers work in rural areas
where 70% of the population live
• Thyolo District, a rural district in southern Malawi, has one of the lowest
number of health workers per capita population of all districts in Malawi
• WHO 2010 policy recommendations: Students from rural backgrounds 2 to 3
times more likely to work in rural areas than those from urban backgrounds,
with targeted admission policies having a significant long term impact
• 2010 Malamulo Scholarship initiative by Médecins Sans Frontières (MSF) and
the Ministry of Health (MOH) to train mid-level health workers at Malamulo
College in Thyolo District; scholarship covers tuition fees and accommodation
One of the Malamulo students
Results
• Of 204 applicants, 80 met minimum entry requirements of Malamulo College
of Health Sciences
• 30 scholarships awarded: 13 nurse-midwives, 10 medical assistants, 5 clinical
officers, and 2 laboratory technicians (Figure 1)
• Mean age on entering programme 22 years; 20/30 (67%) male
• Students will graduate between 2013 and 2015
Education: Use targeted admission policies to
enrol students with a rural background in
education programmes for various health
disciplines, in order to increase the likelihood of
graduates choosing to practice in rural areas.
Regulatory interventions: Provide scholarships,
bursaries or other education subsidies with
enforceable agreements of return of service in
rural or remote areas to increase recruitment of
health workers in these areas.
“There
are
so
many
patients here to see...
sometimes people wait for
hours to be attended to.
Yesterday I was alone on
duty without even an MA
[Medical Assistant] to help
me. Sometimes I have to
do both day and night
shifts in the same day! We
need at least five more
nurses here.”
• Majority stated that they would continue to work in a rural area after satisfying
bonding requirement
• Student concerns: (1) career advancement & lack of opportunity to upgrade
qualifications during bonding period; and (2) harsh living conditions in the rural
areas
Expected year of deployment
# of graduates
WHO 2010 policy recommendations
14
12
10
8
6
4
2
0
13
10
5
3
Deployment 2013
10
5
5
3
2
Deployment 2014
2
Deployment 2015
2
Total deployment
2013 - 2015
Diploma in Nursing and Midwifery Technician Certificate in Clinical Medicine
Diploma in Clinical Medicine
Bio-Medical Sciences- Lab Technician
Figure 1. Expected year of deployment by cadre
Methods
Conclusions
• Needs assessment to identify types of health workers needed most and
geographic areas with the greatest shortages
• Scholarship initiative will reduce, but not fully address, health worker
shortages in Thyolo District
• Scholarships awarded to students from rural areas, prioritising those from
remote areas with the most severe staff shortages
• Success of the scholarship initiative not yet known: Can only be evaluated
several years after graduation
• Enforceable bonding agreements to work in rural health facilities in Thyolo
District for at least 5 years after graduation
• Unknown whether scholarship recipients will continue to work in rural areas
long-term, despite their professed willingness to do so
• Regular contact with scholarship recipients to provide mentoring & support
References
• Database developed to keep track of scholarship recipients with follow-up to
be continued after graduation
1. DFID, MSH, and MSC. Evaluation of Malawi's Emergency Human Resources
Programme. Lilongwe: MSH; 2010.
• Village chiefs and traditional authorities involved in the recruitment process
• Recipients completed a brief questionnaire on entering programme
2. WHO. Increasing access to health workers in remote and rural areas through
improved retention. Global Policy Recommendations. Geneva: WHO; 2010.
CONTACT: Amanda Banda, Email: msfocb-blantyre-hrh@brussels.msf.org, Phone: + 265 1 844 409, Website: www.msf.org