At Work with Malawi's Nurses

More evidence that the brain drain in nurses, doctors and other health care workers is heating up as an issue. Last week, the Lancet devoted a special issue to the lack of skilled health professionals in the developing world. (free to registered users)

Meanwhile I'm plugging along on my Malawi field research project (due to begin in June 2008). Here's the outline I gave the Nieman Foundation of what I plan to do and why. As with any journalistic enterprise, this is by no means the last word. So if you see something you think I'm missing or can suggest other sources, please let me know--preferably by using the comment form below (so that we can all learn a thing or two).

At Work with Malawi’s Nurses

Nieman Fellowship for Global Health Reporting
Proposed Field Project 2008

by Christine Gorman

Principal Goals: To tell the story of what Malawi, a small, land-locked country in southeastern Africa, is doing to hold on to its nurses. To use audio, visual and print media to capture the challenges and opportunities faced by a few Malawian nurses as they consider whether to emigrate to richer countries for higher paying jobs.

Overview: Improving health around the world depends on access to physical resources like clean water and effective medicines, widespread knowledge of best practices in health and medicine and the skilled personnel to deliver all of the above. And yet there is a tremendous and growing shortage of doctors, nurses and other health care workers worldwide. By one estimate the world needs an additional four million health workers—equitably distributed—just to meet minimum standards of health care.

Some parts of the globe are particularly hard hit by the lack of health care workers—especially sub-Saharan Africa. Making matters worse, many rich countries recruit health care workers from poor countries, contributing to the further degradation of services among those who can least afford it. But even the wealthiest nations cannot sustain these stopgap measures forever. For example, it’s becoming increasingly apparent that the current nursing shortage in the U.S. and other rich countries of the world is fundamentally much more severe from previous ones and will soon become so great that those nations cannot simply buy their way out of it.

I would like to use my four-month field project to focus on one piece of this story: the global movement of nurses and how that complicates efforts to improve health care in the poorest parts of the world.

Malawi provides an excellent case study to examine both the push and pull factors in the global migration of nurses. It is a small country that has sent many nurses to England, Ireland and other countries. There’s a growing realization that all other international aid programs will fail unless the health-care-worker crisis is addressed. In 2005, Malawi launched a national program to train and retain health care workers. The program is unique in the development field—and something of an experiment—in that it specifically calls for international funds to supplement the salaries of nurses and other health workers.

Background: With just over 3,000 registered nurses (some sources suggest 7,000) in a country of more than 12 million people in 2003, Malawi does not have anywhere near enough nurses to meet its health care needs. Indeed, when Peter Piot of the UNAIDS and Suma Chakrabarti of the U.K’s Department for International Development (DFID) visited Malawi in 2004, they quickly determined that rolling out a large-scale anti-retroviral HIV treatment program would immediately drain the existing health care system of every available nurse, forcing it to collapse.

It’s not just that Malawi doesn’t train enough nurses to fill its needs but that other countries—particularly South Africa and the United Kingdom—attract a significant share of Malawi’s nursing graduates to higher paying jobs abroad. In 2003, the BBC reported that Malawi graduated 60 new registered nurses but that 100 RNs left for other countries—half of them landing in the U.K. In addition, a growing number of non-government organizations operating in Malawi are pulling nurses out of clinical practice to administrate their programs.


As a partial solution and perhaps in recognition of the role the U.K. has played in draining Malawi of many of its nurses, DFID launched a 100 million pound program to strengthen Malawi’s health care system. A major part of that effort is the Emergency Human Resource Program, which is paying additional salary stipends for nurses and other health care professionals as an incentive to keep them in the public health care system.

Since donors don’t usually pay for salaries of health care workers (and indeed the World Bank and International Monetary Fund frown on such actions, arguing they are unsustainable), DFID and the Malawian government had to persuade the international financial authorities to make an exception in their case. “That was breaking a taboo,” Piot told me in Boston in February 2008 . “Normally, donators don’t pay for salaries—except for people from the donor country. Sorry to be blunt about it.”

How is the Emergency Human Resource Program faring? Are the numbers of nurses working in public hospitals on the rise? Are the stipends large enough to stem the flow of skilled nursing professionals emigrating from Malawi? What other factors—such as working conditions, opportunities for professional development, educational needs of offspring, the possibility of sending remittances to family members—play a role in determining whether a nurse stays in Malawi or chooses to emigrate? What different levels of nursing are there in Malawi and how do their skills complement each other? Has the Emergency Program found the right balance between graduate and auxiliary nurses?

The best way to find out the answers to these and other questions is to go directly to the source—the nurses themselves. By telling a few carefully chosen stories, I hope to give an accurate and in-depth look at the complexity of training and retaining skilled nursing personnel. Because this is a journalistic and not an academic enterprise, I propose to follow the nurses in their daily lives both inside and outside of the hospitals, as they go to market, as they talk about their hopes and dreams for themselves, their families and their country. Have they always had enough to eat? Dealt with violence at home or at work?

Although 85% of Malawi’s population lives in rural areas, most of its registered nurses and doctors practice in urban areas. Private or for-profit health care in Malawi is virtually non-existent. The bulk of health care is provided by the government through the Ministry of Health. An additional, significant player is the Christian Health Association of Malawi, which provides anywhere from 25% to 40% of the country’s health care—much of it centered in rural areas.

Malawi has one university-affiliated nursing school, the Kazumu College of Nursing in Lilongwe, which offers the registered nurse degree as well as other advanced practice degrees. Another eight nursing schools are hospital-based and scattered throughout the country and train so-called “enrolled nurses” who practice under the guidance of a RN.

Based on my studies at Harvard’s School of Public Health and interviews I’ve conducted with Professor Lincoln Chen and others, I already have a number of questions I would like to explore. Going on-site will no doubt reveal new areas to explore in building up the nursing foundation of Malawi’s health system.

Professional photographer Eileen Hohmuth-Lemonick will accompany me on at least part of the trip. She has, among other projects, documented the lives of child soldiers in Uganda and profiled new mothers and their babies in maternity hospitals in Georgia (the country, not the state). Her presence will be a bonus for the Field Project (two for the price of one).

Traditional News Media: Field research in Malawi will serve as the basis for print articles and radio pieces. [ex CG: I snipped a couple sentences here detailing the specific media outlets I'm targeting for freelanced pieces.] The greatest success will likely be in finding and reporting stories that bridge international borders—such as the bond that grows between an elderly American and her Malawian homecare nurse, the competition between international recruiters who travel the world offering nurses the sorts of incentives that will induce them to work abroad.

Multi-Media: A special feature of the project will be the innovative use of internet and interactive media to tell the story of Malawi’s nurses and to fill in the details of the heretofore mostly invisible bridge that links nurses from poor countries such as Malawi to rich countries in the northern hemisphere. Digital slide shows with accompanying audio in the nurses’ own voices will help viewers relate to the choices and challenges these dedicated women and men face. Video clips will provide moving vignettes of nurses as they go about their daily lives—not just in health care settings but as they provide for their families, interact in their communities, consider the recruiting offers made by overseas nursing facilities, etc. These individual segments can be gathered into a single website as well as tailored to the needs of traditional media websites. Video/audio equipment and laptop on loan from Nieman Foundation.

Mapping the story: Let’s face it, most folks would find reading about the “international migration of skilled nursing personnel” a fairly yawn-inspiring endeavor. One way to tell that story in a vivid and more engaging way is through interactive mapping on the web that would trace the migration routes of Malawian nurses. This could work on two levels:

(1) a simpler option would be to aggregate available information collected from academic and other sources, outlining where Malawian nurses live and work around the world. This would be similar to the visualization of international statistics popularized by Hans Rosling of Gapminder.org or Michael Gastner and Mark Newman of Worldmapper.org. In both cases, tables of official figures are turned into visual representations so that relationships and inequities jump out more clearly—a sort of gestalt appreciation of detailed information that can be calibrated to either a global or a local scale.

(2) a more ambitious project would be to create a web-based social network for expatriate Malawian nurses in which they can enter whatever information they would like to share about themselves—hometown, whether they trained, where they are now living and how long they have been there. In addition to providing networking opportunities for communities abroad, such a network would, as it grows, could also support a network for publishing and exchanging global health news.

Such a database, which could also generate news stories as it grows and document trends in migration, could be generated from already existing software such as the People Finder Interchange Format (PFIF), an XML-based standard that was created in the aftermath of Hurricane Katrina to exchange and collate information about missing loved ones.

Expanding coverage of global health issues: The traditional news industry is going through a period of unprecedented retrenchment. International and beat reporting have been pared back dramatically. No one knows how or when this might all settle out. And yet, it is hard to see how improvements in global health can be achieved without sustained attention to global health issues—not simply to raise awareness but also to promote accountability, to document what works and what doesn’t.

The story of Malawi’s nursing crisis will have the greatest impact if it is told through both traditional media and Web-based technologies. I am eager to begin that journey.

Related stories:
Shifting Focus on Malawi's Nurses
Are Donors Promoting Corruption in Malawi?