Why Do They Leave? Challenges to Retention of Surgical Clinical Officers in District Hospitals in Malawi

Document Type : Original Article

Authors

1 Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland

2 Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands

3 Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland

4 Department of Surgery, College of Medicine Malawi, Blantyre, Malawi

5 Radboud University Medical Centre, Nijmegen, The Netherlands

Abstract

Background
Low- and middle-income countries (LMICs) are the worst affected by a lack of safe and affordable access to safe surgery. The significant unmet surgical need can be in part attributed to surgical workforce shortages that disproportionately affect rural areas of these countries. To combat this, Malawi has introduced a cadre of non-physician clinicians (NPCs) called clinical officers (COs), trained to the level of a Bachelor of Science (BSc) in Surgery. This study explored the barriers and enablers to their retention in rural district hospitals (DHs), as perceived by the first cohort of COs trained to BSc in Surgery level in Malawi.
 
Methods
A longitudinal qualitative research approach was used based on interviews with 16 COs, practicing at DHs, during their BSc training (2015); and again with 15 of them after their graduation (2019). Data from both time points were analysed and compared using a top-down thematic analysis approach.
 
Results
Of the 16 COs interviewed in 2015, 11 intended to take up a post at a DH following graduation; however, only 6 subsequently did so. The major barriers to remaining in a DH post as perceived by these COs were lack of promotion, a more attractive salary elsewhere; and unclear, stagnant career progression within surgery. For those who remained working in DH posts, the main enablers are a willingness to accept a low salary, to generate greater opportunities to engage in additional earning opportunities; the hope of promotional opportunities within the government system; and greater responsibility and recognition of their surgical knowledge and skills as a BSc-holder at the district level.
 
Conclusion
The sustainability of surgically trained NPCs in Malawi is not assured and further work is required to develop and implement successful retention strategies, which will require a multi-sector approach. This paper provides insights into barriers and enablers to retention of this newly-introduced cadre and has important lessons for policy-makers in Malawi and other countries employing NPCs to deliver essential surgery.

Keywords

References

  1. Chu K, Rosseel P, Gielis P, Ford N. Surgical task shifting in Sub-Saharan Africa. PLoS Med. 2009;6(5):e1000078. doi:10.1371/journal.pmed.1000078
  2. Ozgediz D, Kijjambu S, Galukande M, et al. Africa's neglected surgical workforce crisis. Lancet. 2008;371(9613):627-628. doi:10.1016/s0140-6736(08)60279-2
  3. Ozgediz D, Riviello R. The "other" neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med. 2008;5(6):e121. doi:10.1371/journal.pmed.0050121
  4. Kruk ME, Wladis A, Mbembati N, et al. Human resource and funding constraints for essential surgery in district hospitals in Africa: a retrospective cross-sectional survey. PLoS Med. 2010;7(3):e1000242. doi:10.1371/journal.pmed.1000242
  5. Grimes CE, Bowman KG, Dodgion CM, Lavy CB. Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg. 2011;35(5):941-950. doi:10.1007/s00268-011-1010-1
  6. Blacklock C, Gonçalves Bradley DC, Mickan S, et al. Impact of contextual factors on the effect of interventions to improve health worker performance in sub-Saharan Africa: review of randomised clinical trials. PLoS One. 2016;11(1):e0145206. doi:10.1371/journal.pone.0145206
  7. Gajewski J, Borgstein E, Bijlmakers L, et al. Evaluation of a surgical training programme for clinical officers in Malawi. Br J Surg. 2019;106(2):e156-e165. doi:10.1002/bjs.11065
  8. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet. 2007;370(9605):2158-2163. doi:10.1016/s0140-6736(07)60785-5
  9. Bergström S. Training non-physician mid-level providers of care (associate clinicians) to perform caesarean sections in low-income countries. Best Pract Res Clin Obstet Gynaecol. 2015;29(8):1092-1101. doi:10.1016/j.bpobgyn.2015.03.016
  10. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. doi:10.1016/s0140-6736(15)60160-x
  11. World Health Organization (WHO), PEPFAR & UNAIDS. Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams: Global Recommendations and Guidelines. Geneva: WHO; 2007.
  12. O'Flynn E, Andrew J, Hutch A, et al. The specialist surgeon workforce in east, central and southern Africa: a situation analysis. World J Surg. 2016;40(11):2620-2627. doi:10.1007/s00268-016-3601-3
  13. The World Bank. Rural Population (% of Total Population). World Bank staff estimates based on the United Nations Population Division's World Urbanization Prospects: 2018 Revision. https://data.worldbank.org/indicator/SP.RUR.TOTL.ZS?most_recent_value_desc=true.  Accessed June 29, 2019. Published 2018.
  14. The World Bank. Malawi: Population. The World Bank; 2018. https://data.worldbank.org/country/malawi.  Accessed January 22, 2020.
  15. Gowshall M, Taylor-Robinson SD. The increasing prevalence of non-communicable diseases in low-middle income countries: the view from Malawi. Int J Gen Med. 2018;11:255-264. doi:10.2147/ijgm.s157987
  16. Varela C, Young S, Groen R, Banza L, Mkandawire NC, Viste A. Untreated surgical conditions in Malawi: a randomised cross-sectional nationwide household survey. Malawi Med J. 2017;29(3):231-236. doi:10.4314/mmj.v29i3.1
  17. Chilopora G, Pereira C, Kamwendo F, Chimbiri A, Malunga E, Bergström S. Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Hum Resour Health. 2007;5(1):17. doi:10.1186/1478-4491-5-17
  18. Shumbusho F, van Griensven J, Lowrance D, et al. Task shifting for scale-up of HIV care: evaluation of nurse-centered antiretroviral treatment at rural health centers in Rwanda. PLoS Med. 2009;6(10):e1000163. doi:10.1371/journal.pmed.1000163
  19. Dockery AM, Barns A. Who'd be a nurse? some evidence on career choice in Australia. Aust Bull Labour. 2005;31(4):350-383.
  20. Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Serv Res. 2008;8:19. doi:10.1186/1472-6963-8-19
  21. Marchal B, Kegels G. Health workforce imbalances in times of globalization: brain drain or professional mobility? Int J Health Plann Manage. 2003;18 Suppl 1:S89-101. doi:10.1002/hpm.720
  22. Carrington MW, Detragiache ME. How Big is the Brain Drain? International Monetary Fund; 1998.
  23. Pang T, Lansang MA, Haines A. Brain drain and health professionals. BMJ. 2002;324(7336):499-500. doi:10.1136/bmj.324.7336.499
  24. Dolea C, Stormont L, Braichet JM. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ. 2010;88(5):379-385. doi:10.2471/blt.09.070607
  25. Booth A, Hannes K, Harden A, Noyes J, Harris J, Tong A. COREQ (consolidated criteria for reporting qualitative studies). In: Moher D, Altman D, Schulz K, Simera I, Wager E, eds. Guidelines for Reporting Health Research: A User's Manual. Chichester, West Sussex: Wiley Blackwell; 2014:214-226. doi:10.1002/9781118715598.ch21
  26. Calman L, Brunton L, Molassiotis A. Developing longitudinal qualitative designs: lessons learned and recommendations for health services research. BMC Med Res Methodol. 2013;13:14. doi:10.1186/1471-2288-13-14
  27. Gajewski J, Bijlmakers L, Mwapasa G, Borgstein E, Pittalis C, Brugha R. 'I think we are going to leave these cases'. Obstacles to surgery in rural Malawi: a qualitative study of provider perspectives. Trop Med Int Health. 2018;23(10):1141-1147. doi:10.1111/tmi.13135
International Journal of Health Policy and Management
Volume 11, Issue 3
March 2022
Pages 354-361

Files

History

  • Receive Date: 04 February 2020
  • Revise Date: 09 April 2020
  • Accept Date: 20 July 2020
  • First Publish Date: 01 March 2022

Share

How to cite

Statistics