Francis Kamwendo

Shortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi’s efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers’ perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi’s women. A qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants’ experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions a in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software. Eighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care. This study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi.

Malawi faces a severe shortage of health workers, a factor that has contributed greatly to high maternal mortality in the country. Most clinical care is performed by mid-level providers (MLPs). While utilization of these cadres in providing health care is a solution to the current shortages, demotivating factors within the Malawian health system are pushing them into private, non-governmental, and other non-health related positions. This study aims to highlight these demotivating factors by exploring the critical aspects that influence MLPs’ intention to leave their jobs.

Background: Mid-level cadres are being used to address human resource shortages in many African contexts, but insufficient and ineffective human resource management is compromising their performance. Supervision plays a key role in performance and motivation, but is frequently characterised by periodic inspection and control, rather than support and feedback to improve performance. This paper explores the perceptions of district health management teams in Tanzania and Malawi on their role as supervisors and on the challenges to effective supervision at the district level. Methods: This qualitative study took place as part of a broader project, “Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers”. Semi-structured interviews were conducted with 20 district health management team personnel in Malawi and 37 council health team members in Tanzania. The interviews covered a range of human resource management issues, including supervision and performance assessment, staff job descriptions and roles, motivation and working conditions. Results: Participants displayed varying attitudes to the nature and purpose of the supervision process. Much of the discourse in Malawi centred on inspection and control, while interviewees in Tanzania were more likely to articulate a paradigm characterised by support and improvement. In both countries, facility level performance metrics dominated. The lack of competency-based indicators or clear standards to assess individual health worker performance were considered problematic. Shortages of staff, at both district and facility level, were described as a major impediment to carrying out regular supervisory visits. Other challenges included conflicting and multiple responsibilities of district health team staff and financial constraints. Conclusion: Supervision is a central component of effective human resource management. Policy level attention is crucial to ensure a systematic, structured process that is based on common understandings of the role and purpose of supervision. This is particularly important in a context where the majority of staff are mid-level cadres for whom regulation and guidelines may not be as formalised or well-developed as for traditional cadres, such as registered nurses and medical doctors. Supervision needs to be adequately resourced and supported in order to improve performance and retention at the district level.

Maternal mortality in much of sub-Saharan Africa is very high whereas there has been a steady decline in over the past 60 years in Europe. Perinatal mortality is 12 times higher than maternal mortality accounting for about 7 million neonatal deaths; many of these in sub-Saharan countries. Many of these deaths are preventable. Countries, like Malawi, do not have the resources nor highly trained medical specialists using complex technologies within their healthcare system. Much of the burden falls on healthcare staff other than doctors including non-physician clinicians (NPCs) such as clinical officers, midwives and community health-workers. The aim of this trial is to evaluate a project which is training NPCs as advanced leaders by providing them with skills and knowledge in advanced neonatal and obstetric care. Training that will hopefully be cascaded to their colleagues (other NPCs, midwives, nurses).

Los trabajadores de salud de nivel intermedio (TSNI) son trabajadores capacitados en una institución de educación superior durante al menos dos a tres años, quienes son autorizados y regulados para trabajar de forma autónoma para el diagnóstico, control y tratamiento de dolencias, enfermedades y discapacidades, así como participar en la prevención y promoción de la salud. Su papel se ha ampliado progresivamente y ha recibido atención en particular en países de ingresos bajos y medios, como parte de una estrategia para superar los desafíos del personal sanitario, mejorar el acceso a servicios básicos de salud y lograr objetivos relacionados con los Objetivos del Desarrollo del Milenio. La evidencia, aunque limitada e imperfecta, muestra que donde los TSNI están debidamente capacitados, apoyados y coherentemente integrados en el sistema de salud, tienen el potencial para mejorar la distribución de los trabajadores de la salud y el acceso equitativo a los servicios de salud, manteniendo –si no sobrepasando– los estándares de calidad comparables a los servicios prestados por el personal médico. Sin embargo, existen desafíos importantes en términos de la marginación y el limitado apoyo a la gestión de los TSNI en los sistemas de salud. La expansión de los TSNI debe tener prioridad entre las opciones de política consideradas por países que enfrentan problemas de escasez y desigualdad en la distribución de recursos humanos. Una mejor educación, supervisión, administración y regulación de las prácticas y la integración en el sistema de salud tienen el potencial de maximizar los beneficios de la utilización de este personal.

Mid-level health providers (MLP) are health workers trained at a higher education institution for at least a total of 2-3 years, and authorized and regulated to work autonomously to diagnose, manage and treat illness, disease and impairments, as well as engage in preventive and promotive care. Their role has been progressively expanding and receiving attention, in particular in low- and middle-income countries, as a strategy to overcome health workforce challenges and improve access to essential health services and achieve the health related targets of the Millennium Development Goals. Evidence, although limited and imperfect, shows that, where MLP are adequately trained, supported and integrated coherently in the health system, they have the potential to improve distribution of health workers and enhance equitable access to health services, while retaining quality standards comparable to, if not exceeding, those of services provided by physicians. Significant challenges however exist in terms of the marginalization and more limited management support of MLP in health systems. The expansion of MLP should have priority among the policy options considered by countries facing shortage and maldistribution challenges. Improved education, supervision, management and regulation practices and integration in the health system have the potential to maximize the benefits from the use of these cadres.

Background: Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. Methods: During a three month period, data from 2131 consecutive obstetric surgeries in 38 district hospitals in Malawi were collected prospectively. The interventions included caesarean sections alone and those that were combined with other interventions such as subtotal and total hysterectomy repair of uterine rupture and tubal ligation. All these surgeries were conducted either by clinical officers or by medical officers. Results: During the study period, clinical officers performed 90% of all straight caesarean sections, 70% of those combined with subtotal hysterectomy, 60% of those combined with total hysterectomy and 89% of those combined with repair of uterine rupture. A comparable profile of patients was operated on by clinical officers and medical officers, respectively. Postoperative outcomes were almost identical in the two groups in terms of maternal general condition – both immediately and 24 hours postoperatively – and regarding occurrence of pyrexia, wound infection, wound dehiscence, need for re-operation, neonatal outcome or maternal death. Conclusion: Clinical officers perform the bulk of emergency obstetric operations at district hospitals in Malawi. The postoperative outcomes of their procedures are comparable to those of medical officers. Clinical officers constitute a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians.