NR 553 Week 7 Workforce Migration Analysis Example

Workforce Migration Analysis: Malawi's Nurses and Doctors Move First From District to City and From Public Service to Program Jobs, Then Abroad, With the Training Bill Left Behind and the Non-Pay Reasons Named

Student Name

College of Nursing, Chamberlain University

NR 553: Global Health

Instructor Name

Month Day, Year

Workforce Migration Analysis: Malawi's Nurses and Doctors Move First From District to City and From Public Service to Program Jobs, Then Abroad, With the Training Bill Left Behind and the Non-Pay Reasons Named

The Question

International migration of health workers from sub-Saharan Africa to high-income countries is well documented. Clemens and Pettersson (2008) assembled data showing that substantial numbers of African-born doctors and nurses were working in wealthier countries around the turn of the century. Malawi, with some of the lowest numbers of health workers per person in the world, has been one of the countries most affected. This analysis argues that international migration is the last stage of a longer movement that starts inside the country, and that understanding the earlier stages matters as much as the border crossing.

Stage 1: District to City

The first move is internal. A nurse trained at a college in Lilongwe or Blantyre is posted to a district hospital or rural health center. Rural postings often mean isolated housing, few schools for children, long distances to family and heavy workloads with few colleagues. Many nurses seek transfers to central hospitals in the cities as soon as they can. The result is that rural facilities, where most Malawians live, have higher vacancy rates than urban ones, even before anyone leaves the country.

Stage 2: Public Service to Program Work

The second move is from the public service to jobs funded by donors and nongovernmental organizations. Programs for HIV, malaria and research often pay more than the government, offer better equipment and provide training, vehicles and per diems. A nurse can stay in Malawi, often in the same city, and double or triple their income by moving to a program post. These jobs do valuable work, but each one filled by a public service nurse leaves a government ward shorter-staffed. Donor financing that flows around the government budget, as the financing analysis showed, is part of what creates this pull.

Stage 3: Abroad

The third move crosses the border. In the early 2000s, significant numbers of Malawian nurses were recruited to the United Kingdom, and others have moved to South Africa, other countries in the region and elsewhere. Record and Mohiddin (2006) described Malawi facing high vacancy rates in its public health system and migration threatening to outstrip training, despite efforts to improve pay and conditions. By the time a nurse leaves Malawi, they have often already moved from district to city and from public service to program work; international migration is the end of a sequence, not a sudden event.

Who Paid for the Training

Training a nurse or doctor in Malawi is largely funded by the government, through public training colleges and the university medical school. When a trained professional moves abroad, the cost of training stays on Malawi's budget while the benefit of the professional's work goes to the destination country. Mills and colleagues estimated the government-subsidized cost of educating doctors in nine sub-Saharan countries and the lost return on that investment for doctors working in destination countries; for Malawi, the estimated lost investment was about $2.16 million, and the benefit to destination countries of recruiting trained doctors was largest for the United Kingdom, about $2.7 billion across the source countries studied (Mills et al., 2011). Malawi's figure was the smallest in the study, reflecting its small number of doctors, not a small loss relative to its budget or needs.

Record and Mohiddin (2006) proposed remedies that address this transfer directly, such as migrating professionals repaying training costs or destination governments remitting part of the taxes paid by migrant health workers. They also noted that migration brings remittances, which go directly to households and can reduce poverty.

Pay Is Not the Only Pull

Pay differences are large and real, but health workers also cite non-pay reasons for leaving public service and the country. They leave workplaces where medicines and gloves run out, where there are too few colleagues to provide safe care, where supervision is absent and where there is no clear path to promotion or further training. They leave for their children's education and for safety. A nurse who cannot give patients the care they were trained to give experiences a particular kind of distress, and that distress is a push factor that higher salaries alone may not fix.

What the Numbers Do Not Capture

The cost estimates for training capture the government's direct investment, but not the full loss. A nurse who leaves a district hospital takes years of experience, knowledge of local patients and the ability to supervise and teach younger staff. Those losses are hardest to replace, because experience cannot be bought with a training budget. The estimates also do not capture the effect on colleagues who stay, whose workloads rise and whose own intention to leave may grow.

On the other side, the numbers do not capture remittances, which Record and Mohiddin (2006) noted can be large and go directly to households, or the possibility that some migrants return with skills and savings. A full account of migration's effect on Malawi would weigh all of these, and the balance would differ for nurses and doctors, for rural and urban areas and for families and the health system.

Responses

Malawi responded in the mid-2000s with an emergency human resources program, supported by donors, that increased salaries for key health cadres, expanded training and brought in volunteer and short-term international staff. The approach showed that retention can respond to pay, but it depended on donor funding.

At the international level, the 2010 WHO recruitment code calls on member states not to recruit actively from countries facing critical shortages and to support source countries' health systems (World Health Organization, 2010). The code is voluntary, and its effect depends on destination countries choosing to follow it.

A response that follows the sequence of migration would act at each stage: improving rural housing, schooling support and staffing to reduce the first move; aligning program pay with the public service to reduce the second; and, for the third, enforcing ethical recruitment in destination countries and exploring the compensation mechanisms Record and Mohiddin proposed.

Each response targets a different stage, and a policy that addresses only the border will miss the moves that happen long before a nurse boards a plane. Monitoring should therefore track rural vacancies and program hiring as well as emigration.

References

Clemens, M. A., & Pettersson, G. (2008). New data on African health professionals abroad. Human Resources for Health, 6, Article 1. https://doi.org/10.1186/1478-4491-6-1

Mills, E. J., Kanters, S., Hagopian, A., Bansback, N., Nachega, J., Alberton, M., Au-Yeung, C. G., Mtambo, A., Bourgeault, I. L., Luboga, S., Hogg, R. S., & Ford, N. (2011). The financial cost of doctors emigrating from sub-Saharan Africa: Human capital analysis. BMJ, 343, Article d7031. https://doi.org/10.1136/bmj.d7031

Record, R., & Mohiddin, A. (2006). An economic perspective on Malawi's medical "brain drain". Globalization and Health, 2, Article 12. https://doi.org/10.1186/1744-8603-2-12

World Health Organization. (2010). WHO global code of practice on the international recruitment of health personnel.