Editorial: The paradox of Malawi’s health workforce shortage: pragmatic and unpopular decisions are needed

Adamson S. Muula 1,2

  1. Professor and Head of Department, Community and Environmental Health, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
  2. Editor-in-Chief, Malawi Medical Journal, Malawi

Email address: amuula@kuhes.ac.mw

Malawi (2023) is experiencing significant health challenges resulting from lack of access to potable water, sanitation and hygiene, consequences of the effects of Cyclone Freddy and a critical shortage of in-post skilled human resources. The country has been battling a cholera outbreak since April 2022 which has claimed at least 1,733 lives as at 10th April 2023. All the country’s districts have been affected with 57,414 cases reported nationwide by 10th April. This figure is obviously an underestimate as many people who experience symptoms do not access the formal health system. They therefore remain unrecorded. There is no reason to believe that the outbreak is under control as deaths continue to be recorded each week.

There is understandable concern that as a consequence of Cyclone Freddy which has destroyed vital WASH (water, sanitation and hygiene) infrastructure, the cholera situation may again get out of hand. As of March 21st, 2023, Tropical Cyclone Freddy had displaced at least 553,614 people, many of whom are sheltering in 543 sites. Some 507 deaths had been reported and 537 people still unaccounted for, according to country’s Department of Disaster Management Affairs (DoDMA).1 All these (Cyclone Freddy, Cholera outbreak) are happening when there are not enough skilled clinical and public health workers in the public health sector.

Malawi is among the 55 countries in the world which are severely constrained in terms of the “availability” of skilled human resources for health working in the country. With respect to countries such as Malawi, the UK government’s ‘Code of Practice for the international recruitment of Health and social care personnel in England2 reads in part, “Consistent with the WHO Global Code of Practice principles and articles, and as explicitly called for by the WHO Global Code of Practice 10-year review, the listed countries should be prioritised for health personnel development and health system-related support, provided with safeguards that discourage active international recruitment of health personnel.” The Code further states that: “Countries on the list should not be actively targeted for recruitment by health and social care employers, recruitment organisations, agencies, collaborations, or contracting bodies unless there is a government-to-government agreement in place to allow managed recruitment undertaken strictly in compliance with the terms of that agreement.” The UK says that: “Countries on the WHO Health Workforce Support and Safeguards list are graded red in the code. If a government-to-government agreement is put in place between a partner country, which restricts recruiting organisations to the terms of the agreement, the country is added to the amber list.” And there lies the Malawi paradox or irony.

Malawi has one medical school at the Kamuzu University of Health Sciences-KUHeS (formerly, the College of Medicine of the University of Malawi) which produces about 100 medical students annually, between 30 and 40 pharmacists, the same number of physiotherapists, laboratory technologists and scientists, and health services management graduates. Hundreds of registered nurses are produced each year at KUHeS, Daeyang Luke University, University of Livingstonia, Mzuzu University and other institutions. The country also produces each year, hundreds of public health professionals both at undergraduate and postgraduate levels.  Yet the Ministry of Health has huge vacancy rates. Malawi’s economy cannot manage to have all the required health professionals employed. The International Monetary Fund (IMF) continues to remind the country’s political and civil service leadership that the public service wage bill cannot be sustained by the economy.

The thousands of health professions’ graduates that Malawi’s higher education institution produce each year remain unemployed because the public health sector cannot afford to employ all of these. Every year, the number of unemployed doctors, nurses, pharmacists, physiotherapists, laboratory technologists and scientists, and others cadres continues to swell. And unlike other countries whose health workforce shortages result from underproduction and outmigration, the situation is different for Malawi. Most of the trained workforce is within the country, but idle. The Malawi government doesn’t have the money to pay for their salaries should they be employed by the public sector. And the previously usual and available destination for Malawian nurses and (some) doctors, i.e. the United Kingdom, says that Malawi is a red country. Unless there is government-to-government agreement, Malawian doctors and nurses cannot be actively recruited. The government of Malawi doesn’t wish to have a government to government agreement with the UK. Yet, Malawi cannot also afford to hire all the (often young) professionals. The country fails to admit that it is in the best interests of young Malawian doctors and nurses to leave the country and serve humanity wherever they can! And the Society for Medical Doctors and the Medical Association of Malawi both remain silent on motivating for the migration of skilled human resources from Malawi. Yes, I cannot believe I am writing this; but what is the solution to the current situation? Burying our heads in the sand is what we have so far done. And it is not helping.

When cholera and Cyclone Freddy hit Malawi, scores of doctors and nurses from elsewhere flocked into the country “because of shortage of human resources” to fight the two problems. This is nonsensical and the international community needs to help Malawi not peddle the false narrative that the country does not have trained human resources for health to deploy to serve its nationals. The World Health Organization’s narrative is in fact complicit in failing to strongly recognise the real problem and support the Malawi Ministry of Health to allow the migration of Malawian doctors while working to eventually, in the medium to long-term, recruit all the health workers that remain idle in the country. The least that the WHO can do is to remove Malawi from the “red list” and have its trained health workers leave the country, for now. I do not think having unemployed doctors and other highly qualified health professionals idle in a country such as Malawi for prestige and ideological reasons is being clever.


  1. Malawi: Tropical Cyclone Freddy – Flash Update No. 7 (22 March 2023) accessed on 10th April 2023 from: https://reliefweb.int/report/malawi/malawi-tropical-cyclone-freddy-flash-update-no-7-22-march-2023
  2. Department of Health and Social Care. Code of Practice for the Ethical international Recruitment of health and social care personnel in England. Accessed on 10th April 2023 from: https://www.gov.uk/government/publications/code-of-practice-for-the-international-recruitment-of-health-and-social-care-personnel/code-of-practice-for-the-international-recruitment-of-health-and-social-care-personnel-in-england

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