Evaluation of Malawi's Emergency Human Resources Programme

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Management Sciences for Health 0.05 per 1,000, respectively. Nurse to population ratios compare similarly – 0.37 per 1,000 in Malawi versus 2.01, 1.14, 0.72, and 0.43, respectively, to the same countries. 78 At the outset of the EHRP in 2004, the total health service provider density 79 was 0.87 per 1,000 population in the public sector (MOH and CHAM). This figure rose to 1.44 by 2009, representing a 66% increase. (Removing HSAs from the health provider density results in ratios of 0.46 per 1,000 in 2004 increasing to 0.64 in 2009.) Over the same period of time, the total population of Malawi increased by 10%. Thus, health provider density outpaced the population increase. 80 Despite these increases, Malawi’s health service provider density is still below the average for the African region (1.91 per 1,000) and further still below the world average (6.23 per 1,000). 81 In addition to calculating health service provider density for Malawi overall, the density by district was examined to determine whether there was an even distribution of staff by the end of the EHRP. The total density in 2009 of the MOH and CHAM 11 priority cadres of staff, in addition to community-based HSAs, is mapped by district in Figure 23 on the following page. 82 Staffing densities could not be calculated for 2004 due to a lack of available data for health provider deployment by district from the MOH and CHAM. The original design of the EHRP did not include specific goals in relation to health worker distribution, but rather provided target staffing goals for the country overall. Only the HSA cadre has been targeted to achieve a specific population ratio of 1 HSA per 1,000 population. Furthermore, while the issue of rural employment and retention was raised with the proposed hardship incentive package, this was never implemented. As of 2009, the majority of districts had a health worker density between 1.0 and 1.5 per 1,000 population. There was a wide range of health worker density per 1,000 population, from 0.86 in Kasungu to 3.61 in Mwanza. Interestingly, the two most urban districts, Lilongwe and Blantyre, had the highest number of staff in absolute terms, yet due to high populations rank low on the distribution of health providers (Lilongwe at 1.07 and Blantyre at 1.23 per 1,000 population, respectively). 78 Yohannes Kinfu, Mario R Dal Poz, Hugo Mercer & David B Evans. The health worker shortage in Africa: are enough physicians and nurses being trained? Bulletin of the World Health Organization 2009;87:225-230. doi: 10.2471/BLT.08.051599 79 In this analysis, total health service provider density is comprised of the 11 priority cadres of staff and community-based HSAs. 80 Health worker density is based on the ratio of staff to population; as population grows, the number of staff must increase proportionally to maintain the same density. If the density in Malawi were the same in 2004 and 2009 this would still represent an increase in the absolute number of health workers, because population increased by 10%. Thus, the 66% increase in health worker density represents a true increase above maintaining the same ratio of staff to population. 81 World Health Organization, The World Health Report, 2006: Working together for health. 82 Health workers at central hospitals are included within the staff densities for the district in which the hospitals are located. The central hospitals are denoted with a star in Figure 22 and are as follows: Kamuzu Central Hospital, Lilongwe; Queen Elizabeth Central Hospital, Blantyre; Mzuzu Central Hospital, Mzimba; and Zomba Central and Mental Hospitals, Zomba. EHRP Evaluation Final Report Page 58
Management Sciences for Health Figure 23. MOH and CHAM Total Health Worker Density per 1,000 population in 2009 83 Migration Source: MOH Monthly Top-Up Reports and CHAM Deployment Figures; map by authors. The migration of health workers out of the country had a significant impact on Malawi’s health workforce. In 2002, out of a total number of 493 doctors born and trained in Malawi, 293 (59%) were working out of the country and out of a total number of 2,248 nurses born and trained in Malawi, 377 (16%) were working out of the country. 84 In the 83 Note that this does not include HSAs. Staff in referral hospitals included with figures for district in which hospital is located. CHAM figures to be added. 84 “A Review of Codes and Protocols for the Migration of Health Workers, Catherine Pagett and Ashnie Padarath; Paper # 50, Regional Network for Equity in Health in East and Southern Africa,” Sept., 2007 EHRP Evaluation Final Report Page 59
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Evaluation of Malawi's Emergency Human Resources Programme

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