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Lives of Malawian Nurses: Stories Behind the Statistics

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Lives of Malawian Nurses: Stories Behind the Statistics Lives of Malawian nurses: Stories behind the statistics Astrida Ieva Grigulis Thesis submitted for the degree of Doctor of Philosophy University College London Centre for International Health and Development UCL Institute of Child Health Declaration I, Astrida Grigulis, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signed: 2010 2 Abstract Malawi lost a significant proportion of its most experienced and qualified nurses to international migration between 2000 and 2005. The lure of overseas life and poor conditions of service at home caused an unprecedented wave of migration. This thesis is about the experiences and motivations of nurses who left Malawi, and of those who stayed behind. Using a qualitative biographical method to examine their experiences along a timeline of key life events, I develop a comprehensive picture of nurse migration. The findings show that nurses’ decisions and experiences have been shaped by demographic and political shifts and by a strong culture of family. Population growth has increased competition for higher education and caused a palpable shift in motives for becoming a nurse. Prospective students now see nurse training as a means to a guaranteed career, or to a marketable qualification which can lead to alternative employment. Working conditions have not improved despite numerous government initiatives, and nurses are still leaving for greener pastures. Many now move to Malawian Non-Governmental Organisations, but before 2005 nurses were able to take advantage of the United Kingdom’s (UK) active recruitment strategy. Most were motivated by the prospect of educational opportunities and the financial survival of their families, who often encouraged them because of the status accorded to migration. Whilst nurses in the UK were pleased with their lifestyle improvements, they found it challenging to integrate into society and the workplace. Many also found it difficult to achieve their educational and financial goals, and the stigma of returning to Malawi empty-handed led them to extend their stay. The enduring high status of migration and its unparalleled benefits mean that the desire to migrate is still strong amongst nurses, and many believe that the recent decline in migration is attributable only to tighter UK immigration restrictions. 297 words 3 Contents pages Title page...................................................................................................................... 1 Declaration ................................................................................................................... 2 Abstract ........................................................................................................................ 3 Contents pages ............................................................................................................ 4 Acknowledgements..................................................................................................... 11 Abbreviations.............................................................................................................. 12 Chapter 1 Introduction ............................................................................................. 14 1.1 Structure of the thesis........................................................................................... 16 1.2 Explanation of terms ............................................................................................. 17 Chapter 2 Literature review...................................................................................... 19 2.1 Chapter introduction.............................................................................................. 19 2.1.1 Process .......................................................................................................... 19 2.1.2 Global human resources for health: an overview............................................20 2.2 The United Kingdom ............................................................................................. 22 2.2.1 Overview ........................................................................................................ 22 2.3 Malawi .................................................................................................................. 22 2.3.1 Overview ........................................................................................................ 22 2.4 History .................................................................................................................. 24 2.5 Health in Malawi: an overview............................................................................... 28 2.5.1 The health system.......................................................................................... 29 2.6 Human resources for health in Malawi .................................................................. 32 2.6.1 Overview ........................................................................................................ 32 2.6.2 Nurses in Malawi............................................................................................ 32 2.6.3 Nurse training in Malawi ................................................................................. 34 2.6.4 HRH statistics................................................................................................. 36 2.7 Why are there health worker shortages?............................................................... 38 2.7.1 Overview ........................................................................................................ 38 2.7.2 Supply issues ................................................................................................. 39 2.7.2.1 The current training situation.................................................................... 42 2.7.3 Health challenges........................................................................................... 43 2.7.4 Retention factors ............................................................................................ 46 2.7.4.1 Overview.................................................................................................. 46 2.7.4.2 Working hours.......................................................................................... 47 2.7.4.3 Management issues................................................................................. 47 2.7.4.4 Working conditions................................................................................... 48 2.7.4.5 Salaries.................................................................................................... 48 2.7.5 Leaving the Malawian workforce .................................................................... 49 2.8 Migration from Malawi........................................................................................... 51 2.8.1 Why the UK?.................................................................................................. 54 2.8.2 Destination UK ............................................................................................... 55 2.9 Consequences of migration .................................................................................. 58 2.9.1 Overview ........................................................................................................ 58 2.9.2 Benefits of migration....................................................................................... 60 2.9.3 Costs of migration .......................................................................................... 62 2.9.3.1 Source country costs ............................................................................... 63 2.9.3.2 Nurse migrant costs................................................................................. 65 2.9.4 Conclusion ..................................................................................................... 69 2.10 Theories of international migration...................................................................... 70 2.10.1 Patterns of migration from Malawi ................................................................ 74 2.10.2 Limitations of the push and pull model..........................................................78 4 2.10.3 Conclusion ................................................................................................... 80 2.11 Push and pull factors as solutions....................................................................... 80 2.11.1 Addressing the push..................................................................................... 81 2.11.1.1 Overview of global solutions .................................................................. 81 2.11.2 Malawian solutions and the EHRP................................................................ 82 2.11.2.1 Overview of solutions............................................................................. 82 2.11.2.2 The Emergency Human Resources Programme.................................... 83 2.11.3 Addressing the pull....................................................................................... 84 2.11.3.1 Codes of practice................................................................................... 84 2.11.3.2 General destination country solutions .................................................... 88 2.12 Chapter conclusion ............................................................................................
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