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 government with support from international donors, initiated a six-year programme to increase the availability and retention of qualified health staff.  The Emergency Human Resource programme has three components: a 52 percent salary increase for health professionals, improved capacity at training institutions, and short term recruitment of additional foreign volunteer doctors and nursing tutors. 

This paper from the Overseas Development Institute’s Economic and Statistical Analysis Unit reports on a study regarding the employment preferences of public sector registered nurses in Malawi. Its findings have relevance for the design of incentives encouraging nurses to remain employed within the Malawi public sector health service.

The research method used was a discrete choice experiment, which is a quantitative technique derived from consumer preference surveys. Six job attributes were identified through in-depth interviews with public sector nurses: place of work, net salary, availability of resources, workload, housing provision and opportunities for further education. For each attribute a base level was set corresponding to existing working conditions, with additional levels representing a reasonable improvement over the base level. These were used to construct hypothetical job descriptions. Participants each considered fifteen pairs of job descriptions and were asked which they considered the best job, and which, given their current circumstances, they would choose.

Statistical analysis of the responses revealed that:

• The overwhelming majority indicated that increased salaries would improve retention of registered nurses in the public sector.
• Improving the availability of resources and opportunities to upgrade qualifications would also increase retention.
• Notwithstanding the preference for higher pay levels, all six of the attributes were found to have a statistically significant effect on job satisfaction.
• While housing provision was valued, no significant difference in satisfaction was found between provision of basic or superior levels of housing.
• There was a perception that the best jobs were located in cities, however, taking into account their circumstances, both urban and rural respondents expressed a preference for jobs in district towns.

The findings show that nurses may be willing to sacrifice increases in salary in favour of improvements in other aspects of their working conditions. The Malawi government therefore has access to a range of strategies to improve the value that registered nurses place on their employment in the public sector. Recommendations for policy include:

• The government’s strategy of increasing pay levels is likely to have a positive impact on how registered nurses value their employment.
• Improved pay was the single most important attribute identified that might improve job satisfaction, followed by opportunities for further education and the provision of basic housing.
• Improvements in the quality of housing provided would have little impact on how nurses value their employment.
• Establishing the relationship between pay increases and retention of registered nurses would require additional research.

Source(s):
‘Addressing the Human Resource Crisis in Malawi’s Health Sector: employment preferences of public sector registered nurses’, ESAU Working Paper no 18, Overseas Development Institute, London, by Lindsay Mangham, March 2007

Funded by: Economic and Statistical Analysis Unit, Overseas Development Institute

id21 Research Highlight: 4 April 2008

Further Information:
Lindsay Mangham
Health Policy Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London
WC1E 7HT, UK

Tel: +44 (0) 20 7927 2148
Fax: +44 (0) 20 7637 5391
Contact the contributor: Lindsay.Mangham@lshtm.ac.uk

Health Policy Unit, London School of Hygiene and Tropical Medicine

Other related links:
'Could health worker migration bring benefits to Malawi?'

'Responding to the health workforce crisis'

'The crucial contribution of overseas volunteers'