Health Workforce Innovative Approaches and Promising Practices Study. Attracting and Retaining Nurse Tutors in Malawi. March 2006

Transcription

1 Health Workforce Innovative Approaches and Promising Practices Study Attracting and Retaining Nurse Tutors in Malawi March 2006 Consultants Margaret Caffrey Graeme Frelick Capacity Project USAID Global Health/HIV/AIDS and the Africa Bureau Office of Sustainable Development

2 Table of Contents Abbreviations and Acronyms... ii Acknowledgments... ii Executive Summary Introduction Presentation of the promising practice Overview History Activities to Implement the Promising Practice: The Nurse Tutor Incentive Package Achieved Results Summary Meetings and Interviews Discussion and Perspectives Facilitating factors Constraints Lessons learned Recommendations References Annex A: Proposed Output Indicators for Training Annex B: Tutor Situation in CHAM Training Colleges Annex C: Contacts Met Annex D: Interview Guides Annex E: Emoluments for Nurses Annex F: Interview Notes i

3 Abbreviations and Acronyms CHAM Christian Health Association of Malawi DFID Department for International Development EHRP Emergency Human Resource Programme GTZ German Technical Cooperation HIPC Highly Indebted Poor Countries HRH Human Resources in Health ICCO Interchurch Organization for Development Cooperation IMA Interchurch Medical Assistance KCN Kamuzu College of Nursing LATH Liverpool Associates in Tropical Health MK Malawi Kwacha 1 MOH Ministry of Health NCA Norwegian Church Aid NMCM Nurses and Midwives Council of Malawi NT Nurse Technician NMT Nurse Midwife Technician RN Registered Nurse SETP Six-Year Emergency Pre-Service Training Plan SWAp Sector Wide Approach TRG Training Resources Group, Inc. USAID United States Agency for International Development VSO Volunteers in Service Overseas Acknowledgments This assignment was carried out by the Capacity Project of USAID. The Project Number is GPO-A and funding for this study comes from the Office of Sustainable Development, Africa Bureau and Global Health/HIV/AIDS. The Capacity Team is grateful for the collaboration from Lilongwe-based leadership of MOH, in particular the Permanent Secretary, the CHAM Secretariat, the KCN, the NMCM, bilateral assistance organizations including GTZ, DFID, NCA, and USAID/Malawi, the staff and tutors of the CHAM-affiliated training institutions who took valuable time away from their duties to provide the team with their views and experiences. Finally, special thanks go to the LATH office staff for their very helpful and friendly logistical support and assistance, and to Management International for its preparatory work. The Capacity Project Team bears full responsibility for the report. 1 In March 2006, the exchange rate was about 130MK to 1US$. ii

4 Executive Summary Background The USAID Africa Bureau commissioned the Capacity Project to conduct multi-country studies on health workforce innovative approaches and promising practices. The countries selected for this study are Ghana, Uganda, Malawi, Namibia and Zambia because their governments and collaborating partners have implemented innovative initiatives and/or promising practices for managing the health workforce. USAID will share and disseminate these approaches among governments, WHO, donors, NGOs, the World Bank/IMF and other implementing partners. This paper focuses on Malawi s nurse tutor retention scheme, chronicling the elements of the approach that are successful for purposes of eventual replication, and suggesting how to address some of the challenges. The Capacity Project consultants were Margaret Caffrey of LATH and Graeme Frelick of TRG, who worked to prepare this paper in Malawi from February 27 through March 10, The paper identifies successful approaches for providing top up and other incentives for nurse tutors who train nurse technicians, whose service is primarily in rural and deprived areas. The significance of this scheme to the Malawi health system as a whole is that the shortage in nurse technicians, essential to the health care delivery system, exceeds 80% in several districts. Several other countries in Africa are facing the same challenges and may benefit from this experience in Malawi. The shortage in nurse tutors in the late 90 s was such that several training institutions were on the verge of closing down. The response was to provide top up incentives to attract and retain nurse tutors, starting in The incentive program had its ups and downs, but it was ultimately deemed successful in attracting and retaining nurse tutors, particularly since the inception of GTZ support in In 2000 there were 39 tutors and 12 assistant tutors and as of September 2005 there were 71 tutors and 22 assistant tutors across the 10 nurse technician training institutions operated by members of the Christian Health Association of Malawi. In 2004 the Malawi MOH developed a Sector Wide Approach (SWAp) which has a Program of Work until 2010 addressing the key human resource issues, particularly health worker retention. The lessons learned so far from the tutor incentive package, which predates the SWAp, can be instructive for consideration in its implementation. Findings The key findings of this paper are that the nurse tutor retention scheme was successful at retaining tutors, with such features as: salary top ups free staff housing obligation to serve for a period of time in return for educational scholarships (bonding) Additional incentives offered by some institutions have proved effective at retaining nurse tutors, including: 1

5 Additional salary top ups Transportation to work for commuters Transportation for home visits Training and educational opportunities Free utilities. Other key factors in attracting and retaining tutors are: Proximity to home and to family Promotions within institutions. The retention scheme was targeted and selective, which contributed to its success. Planners knew that the supply of tutors was scarce and worked to ensure that there would be a reliable supply. Public and private partnership through seconding of government health workers to private, faith-based training institutions is another important feature of the scheme. Constraints Factors that constrain the effectiveness of such a retention scheme are: Government employees seconded to CHAM institutions as tutors have no promotion prospects until they return to government service; Monetary incentives can be perceived as an entitlement and no longer serve their initial purpose; Forcing people into positions and careers in which they are not interested reduces their commitment to the job; Weak human resource management systems and practices, including followthrough on the conditions of scholarships, deployment, enforcement of bonding, support to and communication with seconded government workers; The length of time it takes to produce tutors reduces supply; Educational opportunities may reduce the available supply. Recommendations The recommendations to strengthen workforce planning and support for this type of initiative are to: Balance long-term considerations, such as career development with short-term responses to workforce shortages such as monetary retention schemes; Recognize the tutor position in the scheme of service and offer career progression for government workers regardless of employment arrangements; Offer relevant training opportunities such as short courses that allow tutors to continue their service with minimal interruptions; Invest in non-monetary incentives, such as housing and instructional facilities, that are sustainable and build institutional capacity; Review retention schemes on a regular basis to ensure that they meet people s needs and achieve their intended purpose; Strengthen communication of the purpose of retention schemes with existing and potential health workers; Ensure adequate and ongoing support, such as supportive supervision, discussion of work and welfare issues, and eliciting feedback. 2

6 1. Introduction The shortage of Health Workers in Malawi has been at a crisis point for at least the past eight years. Currently, of the 6,084 established nursing positions, 64% are vacant. Six districts have nurse vacancy rates of more than 70%. 2 A 2002 health facility survey found that 15 of the 26 districts had less than 1.5 nurses per health facility while five districts had less than one nurse per facility. 3 In the medical specialties vacancy rates range between 77% and 100%. Malawi has fewer than two doctors per 100,000 population (Tanzania has 4.1; Zimbabwe 13.9; and South Africa 53.6). Malawi has 28.6 nurses per 100,000 population (Tanzania has 85.2; Zimbabwe has 128.7; and South Africa 471.8). There are 10 districts in Malawi with no MOH physician and four with no physician at all. These shortages are due to several factors. As in many southern African countries, the HIV/AIDS pandemic is depleting the ranks of the health workforce. Out of a population of 12 million people in Malawi, over one million between the ages of 15 and 49 are infected with HIV. In Zambia and Malawi, death of nurses represents almost 40% of the annual output from training. 4 In Malawi, the high death rate among health workers of up to 2% per annum has been attributed to HIV/AIDS 5. Other important factors include: Low outputs of training institutions relative to the need for health workers because of low capacity and resource constraints, High failure rates of undergraduate (BSc) nurses on nursing certification exams, Non-competitive remuneration packages, Lack of well structured and clear deployment policy, Lack of an attractive career structure, Lack of an objective appraisal system, Graduates in the health professions, mostly males, choosing other careers that are more attractive especially with NGO s and donor-funded projects, An increase in the numbers of health professionals retiring early and moving to other occupations, Migration to other countries, primarily the UK. From 2000 through 2005, the Nurses and Midwives Council of Malawi validated a total of 616 nurses for practice in other countries. Since 2002, of the 386 who certified, 322 planned to go to the UK. 6 The numbers leaving Malawi may be higher since there is evidence to suggest that many nurses pursue careers other than nursing. Although higher salaries abroad attract Malawian health professionals, many nurses in particular are repelled from public sector work due to poor working conditions and unequal access to training opportunities. This issue is particularly problematic for government 2 Ntaba, Hetherwick, Minister Of Health, Malawi (2006) Improving Retention of HRH in Malawi. A paper presented at the Eastern Central and Southern African Health Community (ECSA) Meeting of Region Health Ministers, Feb 6-10, 2006 in Mombassa, Kenya.. 3 Government of Malawi and Japan International Cooperation Agency. (2002). Malawi Health Facility Survey 2002 Report. Ministry of Health and Population. 4 WHO/World Bank (2004) Health workforce challenges: lessons from country experiences. High Level forum on Health Millennium Development Goals (MDG) 5 Harries AD (2002) High death rates in health care workers and teachers in Malawi. Tans Roy Society topical Medicine &Hygiene 96: Nurses and Midwives Council of Malawi (February 20, 2006). Nurses Validated Abroad. 3

7 nurses seconded as tutors to non-government training institutions. These nurses fall off the government radar screen for the period they are seconded; as a result they do not learn of and are not given access to training opportunities offered to their government colleagues. The MOH deployment procedures are unclear. There are currently few mechanisms in place to manage the movement of staff into and through the health service and between the public and private sectors. There is limited information to inform deployment decisions. Currently there is still an imbalance between urban and rural postings as well as between tertiary and primary level care facilities. There is little tracking to ensure that people go to their posts, and whether they stay. Generally, there is little or not consultation with health workers regarding their assignments. This lack of procedures and consultation has a negative impact on attraction and retention of the health workforce. Staff attitudes towards their deployment are also weakened by the inconsistency in the application of personnel regulations and policy. There is no visible functioning performance appraisal system. Therefore it is hard to ensure quality, to encourage positive performance, to address performance problems, and to ensure career development. There are no visible links between incentives and performance. In order to address the extreme human resource crisis in Malawi, the MOH produced several plans and reports between 2001 and 2004, first describing the health workforce crisis and requesting donor support in key areas such as staff retention and reduction of brain drain, as well as strengthening the capacity of training institutions in order to increase the output of health workers. Then in a more comprehensive manner, the MOH developed a proposal to donors entitled the Six-Year Human Resource Relief Programme for the Malawi Health Sector (EHRP) 7. One of the elements of the program is to make health worker terms and conditions more attractive. After making some downward adjustments, the program resulted in a 52 percent salary increase for all health workers starting in April 2005, whose impact was reduced by new taxes applied to areas such as allowances that had not previously been taxed. The other area secured funding to increase the number of nurses to be recruited. This program is underway and includes funding from a variety of bilateral aid organizations that seek to help Malawi recover from the health workforce crisis. 2. Presentation of the promising practice 2.1 Overview In the late 1990s the Ministry of Health recognized that there was a severe shortage of human resources for health (HRH) and that there was a need for urgent action. The shortages were particularly severe amongst nurses as a result of inadequate supply and production and increasing migration. The majority of nurses were being trained in training institutions managed by the Christian Association of Malawi (CHAM); however the numbers being produced were very small i.e. 10 to 15 per year and mainly for staffing the CHAM hospitals. In 1999, six of the nine CHAM institutions were essentially 7 Martin -Staple, Anne L. (2004). Proposed 6-Year Human Resource Relief Programme For The Malawi Health Sector: Retention, Deployment And Recruitment. Health Strategies International L.L.C. 4

8 closed due to a lack of tutors and the remaining three had a combined intake of 59 trainees. Data available at this time show that 240 nurses per year were being lost to the health sector through death, retirement, and resignations and migration. 8 Since the late 1990s, the Malawian health sector has adopted a comprehensive approach to addressing Human Resources for Health constraints. It has developed and pursued a range of short term and long strategies related to the training, attraction, recruitment, deployment and retention of health workers. It recognized that the supply and production of health workers, particularly nurses, would be dependent on having the training institutions fully functional and adequately staffed. To ensure this it developed and implemented training and retention strategies to address nurse tutor shortages in the CHAM training institutions. The key initiatives are described below. 2.2 History In November 2001, the Ministry of Health (MOH) developed a 6-Year Emergency Pre- Service Training Plan (SETP). It focused on the most essential training needs, including the production and retention of nurse tutors to staff the training institutions. The SETP proposed increasing the enrollment of Nurse Technicians at CHAM training institutions to 410 per year by It planned for the training of 60 Generic Registered Nurses, who would be serve as tutors and clinical instructors and the training of clinical nurse tutors, nursing tutors, and tutors for technical support services through post-basic training programs. (See Annex A: Proposed Output Indicators for Training) The forecast for the planned interventions was to produce over 15,000 health workers by the end of the plan period, 2,000 of which would be existing staff receiving upgrading courses. 9 To address the HRH issues not covered in the SETP, the MOH, in 2004, developed an Emergency Human Resource Programme (EHRP). It provided updated information on the staffing situation and showed a total vacancy rate of 33% and a vacancy rate of 64% for public sector nurses. The program included a range of solutions to address staffing shortages, with specific strategies to improve the recruitment and retention of nurse tutors to reach staffing targets. One of the key studies that informed the development of the EHRP found that although the MOH was seconding tutors to the training institutions, many were not going to their respective posted institutions, primarily because of geographical isolation and conditions of service. One of the recommendations of the study was to revise and maintain the short term incentive package, even after GTZ funding. However, it also proposed some long term strategies as follows: The training of sufficient tutors to meet the regulatory requirements of tutor to student ratios. Development of a career structure for tutors. Revision of conditions of service not only to retain those in service but to attract more tutors into the system Status Report on discussions with the MoHP on the Special Programme for medical doctors and new MoPH proposal for use of funds 9 World Bank (2004) Human Resources and Financing for Health in Malawi 10 Ministry Of Health, Republic Of Malawi (2004). Human Resources in the Health Sector: Toward A Solution. 5

9 It was at this time that the MOH reviewed the 2001 targets for the emergency training program and all of the training institutions updated their plans for increasing student enrolment to meet targeted graduation levels. The institutions estimated that approximately 160 new tutors and senior academic staff would be required to achieve the expanded enrollment levels. The key factors contributing to the non-achievement of the targets were funding shortfalls, lack of student and staff housing, lack of adequately trained tutors; and poor access to qualified students. 11 The Ministry of Health s Programme of Work ( ) incorporated all of the above programs and plans, which receive funding from the MOH budget, the SWAp, the Global Fund, HIPC funding and other donor funds. In 2005, the MOH developed a draft HRH strategic framework to ensure the harmonization and strategic alignment of the various HRH plans, strategies and activities. The framework proposes various strategies and activities to increase the number of trained health workers in the sector. These include ensuring all training institutions are operating at 100% capacity and that existing tutor/student ratios are in line with national standards (1:10). It proposes developing institutional staffing plans to guide and direct the recruitment, career development and retention of tutors; developing retention packages based on a mix of monetary and non-monetary incentives tied to position and performance (e.g. top-ups, housing, teaching facilities and materials, career advancement and training opportunities, support systems, etc.); developing and implementing performance management systems for tutors; and developing indicators to monitor their retention and performance. 2.3 Activities to Implement the Promising Practice: The Nurse Tutor Incentive Package The MOH and CHAM recognized that the shortage of tutors was a key constraint to producing the number of nurses required by the health sector. Since the late 1990s, the training institutions have been experiencing a shortage of qualified tutors, varying in degree from year to year. The majority of the training institutions were not meeting the national recommended tutor to student ratio of 1:10. At times the tutor shortage was so critical that the Nurses and Midwives Council had to close some of the CHAM training institutions. Tutor shortfall is related to poor retention of the available tutors due to poor compensation, remoteness of training institution, poor living and work conditions and deployment practices 12. It is evident from the efforts described above that the health sector has attempted to address the production, recruitment and retention of health workers and nurse tutors in particular in a comprehensive manner. In its efforts to achieve training targets, the Ministry of Health has worked in close collaboration with CHAM to ensure that the training institutions are functioning and adequately staffed. Since 1997 the following organizations and mechanisms provided funding for these initiatives: MOH, HIPC, 11 Martin-Staple, A. L. (2004) Proposed 6-Year Human Resource relief programme for the Malawi Health Sector Part II: training and tutor incentive 12 Martin-Staple, A. L. (2004) Proposed 6-Year Human Resource relief programme for the Malawi Health Sector Part II: training and tutor incentive 6

10 Interchurch Organization for Development Cooperation (ICCO), German Technical Cooperation (GTZ) and Norwegian Church Aid (NCA). From 1999 to date the MOH, with the assistance of funding organizations, provides the following support: student and staff grants to the institutions so that cost (i.e. student fees) and staff salaries are not a barrier to increased enrollment; funding for the training institutions operational costs; scholarships for direct entry BSc in nursing, producing Registered Nurse generalists and for 2-year BSc programs in Nurse Education, Health Management, or Community Health Nursing in order to improve the supply of nurse tutors; bonding and seconding graduates/nurse tutors for 2 years to work in the training institutions in return for fully paid tuition; supporting the recruitment of expatriate nurse tutors through VSO to fill tutor shortfalls in the short term; infrastructural development programs in many of the institutions to improve and expand training facilities, and staff and student accommodation. In addition, CHAM has secured donor support for a tutor retention scheme to improve staffing and attract and retain both CHAM and government seconded tutors. The salary top-ups for nurse tutors were deemed necessary to attract sufficient staff to keep the training institutions functioning and to achieve the planned enrolment targets. From 1997 to 2001, the CHAM institutions received support from ICCO for tutor incentives (including salary top-ups, telephone and electricity allowances, education scholarships, children s school fees) and student sponsorship 13. From 2000 to 2006, the German Technical Cooperation (GTZ) provided salary top-ups for tutors valued at 7,500 MK for Tutors and half of that amount, or 3,750 MK, for Assistant Tutors, as well as for student sponsorship, and curriculum development. The salary top-up was to cover the following: a) Transport costs for visiting family and shopping b) Electricity and water c) Medical services (for tutor, children and spouse) CHAM also employs various other strategies to motivate and retain the CHAM tutors. These include the development of a career structure for nurse tutors in 2005 for those whom the CHAM affiliated institutions employ, which offers promotion opportunities through several levels. In 2006 it began recruiting and promoting staff against this career structure. It includes the following grades: 1. College Principal 2. Principal Tutor 3. Senior Tutor 4. Tutor 5. Assistant Tutor 6. Clinical Instructor 13 MoHP (2001) Proposal for the continuing CHAM Training School students and tutors under ICCO funding to be recruited under the HIPC Programme 7

11 With the support of Norwegian Church Aid it organizes exchange programs, whereby Norwegian tutors provide specialized training programs in the CHAM institutions and CHAM tutors go to Norway for training in specialized healthcare topics and teaching methods, which is helping to improve tutor teaching skills and methodology. CHAM also provides tutors with training and education scholarships for short courses, and degree and masters programs, some of which are funded by Cordaid 14. It has also received funding from Norwegian Church Aid for the construction of teaching and staff and student facilities. In order to attract and retain increased numbers of essential health workers, the government provided a 52% salary increase for 11 cadres or staff categories, including nurse tutors in March Health workers received another salary increase in 2006, which has doubled the salary of higher level health workers. In line with national pay reform policy, which consolidated salaries and allowances, and to continue to support the retention of critical cadres, the MOH is advocating the payment of non-monetary incentives for specific groups of health workers. In 2005, it approved a proposal for short-term and long-term incentives for nurse tutors at CHAM training institutions and professional health workers deployed at difficult to reach remote public health facilities in Malawi. The non-monetary incentives proposed are as follows: promotion for CHAM tutors against the tutor career structure; free housing; free medical services; subsidized utilities; transportation for shopping; education and training opportunities; loan schemes improved supervision, mentoring and communication systems The GTZ funding for top ups was due to be phased out in June When the GTZ funding of incentives stopped in recognition of the 52% salary increase for health workers, CHAM received a communiqué signed by all principal tutors to the effect that government seconded tutors whose contracts were about to end expressed interest to go back and work in hospitals if the incentive is not reconsidered. This was at a time when 50% of the government tutors were due to complete their contracts in December 2005, which would have meant that the number of tutors would have been reduced by 50%, and could have forced some of the training schools to close again. GTZ agreed to continue funding the top-ups until February 2006, while the government and CHAM agreed upon a new strategy. In 2006 CHAM agreed with the MOH that it would maintain the monetary incentives to tutors and fund them using a percentage of the overhead it receives for administering the MOH funded student grants. 14 Cordaid is an international development organization that regroups four Dutch associations: Bilance, Memisa, Mensen in Nood and Vastenaktie. 8

12 3. Achieved Results 3.1 Summary All of the nurse training institutions have remained open since the top up program began in The number of nurse tutors and clinical instructors has increased and remains relatively stable to date with some fluctuations. Numbers of nurse tutors (T), assistant tutors (AT), and clinical instructors (CI) staffing the 10 CHAM institutions Year T, AT, CI (See Annex B: Tutor Situation in CHAM Training Colleges 17 ) Anecdotal information suggests that in 2002/03 after the introduction of GTZ top-ups 80% of those posted arrived at their posting and stayed, which explains why the numbers climb after 2002 after a dip in Furthermore there was an increase in the numbers applying to CHAM for jobs as tutors. CHAM reports that enrollment has grown from approximately 100 graduates in 1999 to 396 in 2005 against a target that year of 400 students. 18 Enrollment data for September 2005 indicates that the institutions have a total enrollment in years 1, 2 and 3 of 764 students. In 2005, CHAM and the MOH set a goal for the training institutions to increase intakes to 500 per year by Anecdotal information suggests that intakes in April 2006 will even exceed the 500 target. CHAM institutions produce over 70% of the frontline cadre of nurses (nurse/midwife technician) required by the health sector and manages 10 of the 11 training institutions producing nurse/midwife technicians. 19 By ensuring that tutors are attracted and retained in these institutions, the health sector can improve the supply of this critical and essential cadre. CHAM has resources to continue most of the top up program through the overhead each institutions charges on government funded nursing student scholarships. 15 The range shown from 2004 through 2006 is due to the difference in the way that Malamulo College of Health Sciences counts its tutors. It appears they include part-time tutors as well as professors from the college who teach occasional classes. Using the lower number is probably a more accurate reflection of the numbers of full-time tutors, based on the numbers the Malamulo College staff shared with the Capacity Team. 16 A total of 11 out of 26 clinical instructors are VSO s 17 The Annex contains a CHAM provided breakdown by institution and by staff category. 18 CHAM (2005) CHAM Training Colleges Comprehensive Plan 19 CHAM (2005) CHAM Training Colleges Comprehensive Plan 9

13 3.2 Meetings and Interviews The Capacity Project team met with 36 people. (See Annex C: Contacts Met) The team conducted a mix of interviews and focus groups with them depending on availability and on the appropriateness of the situation. (See Annex D: Interview Guides) Starting at the national level with the Ministry of Health, the Christian Health Association of Malawi (CHAM), the Nurses and Midwives council of Malawi, the Kamuzu School of Nursing, University of Malawi, and representatives of bilateral aid organizations, the team then visited five of the CHAM-affiliated nurse training institutions in the central and southern regions of Malawi. The team also conducted a brief survey with leaders of all ten CHAM-affiliated institutions during one of their quarterly meetings in Lilongwe. Everyone agrees that the tutor retention scheme succeeded in keeping the ten CHAMaffiliated nurse training institutions staffed with enough tutors for them to operate. Depending on their vantage point, people have different views as to the sustainability and even the desirability of the monetary portion of the scheme, and everyone has questions about its future in the medium to long term. The tutors see the top ups as essential, as do those managing the nurse training institutions. Ministry of Health and bilateral aid agencies have a different view, and would like to end monetary incentives in favor of non-monetary incentives. The Capacity team tried to compile and analyze information about tutors from the time they entered their post-basic training through their posting, including the length they served, and where they went afterwards. They accomplished only a partial reconstruction of these events because some documents have no date, data tends not to be compiled or analyzed on a systematic basis, people remember details of events differently, and the hard drive of a computer with all data about tutors prior to 2004 had crashed with no possibility of retrieval. Although not everyone can recollect the specifics of tutor flow from intake into postbasic training to their eventual exit from CHAM training institutions, everyone has a story to tell and an opinion to share. Since most of the nurse tutors are seconded from government, their concerns were the most widely shared. All tutors want to maintain and even increase their monetary incentives, which vary depending on the additional top up some institutions offer. A few institutions offer additional top ups, mostly around 4,000MK. In one institution the Principal receives an additional top up of 12,000MK, and the Principal tutor receives 8,000MK. Those tutors who work close to where their families live are more likely to be happy with their situation and even to extend their service beyond the two year contract to which they are bound. Many tutors have to maintain two households because they work far from where their families live; as a result they plan to leave as soon as their contract is over. No one sees the April 2005 salary increase of 52% as meaningful. The reasons are that it is based not only on very low salaries, but also on the base salary. If one takes a base salary of 6,000MK 20 that amounts to an additional 3,120MK. Then the government taxes the entire amount of emoluments, including the additional 16,100MK in previously untaxed allowances. The result is an actual increase in take home emoluments of 2,000MK. (See Annex E: Emoluments for Nurses) 20 At an exchange rate of 130MK to 1US$, the base salary would be 46US$. 10

14 The Mulanje School of Nursing conducted a retention survey, which generated the following rank ordered results regarding what are the major factors that nurse tutors consider when deciding to stay or leave: 1. Incentives 2. Housing availability and quality 3. Further training/career options This survey seems representative of what the Capacity Team heard in other institutions. After incentives, housing is the most common concern. There is not enough of it, and that factor keeps institutions from attracting and retaining nurse tutors, and from increasing the numbers of nursing students. Norwegian Church Aid is building several tutor housing units in response to that concern. It is part of their contribution to the SWAp. NCA is even building capacity in the local construction trade through the training and certification of masons and carpenters, among others. The program is moving along apace, though it has slowed down from the initial schedule to ensure quality. Tutors are impatient to see the construction move forward so that they can enjoy better living conditions, and school administrators are looking forward to attracting more tutors. Working and living conditions for students are on the minds of principal tutors. Student hostels and additional classrooms are another feature of the NCA construction program. In addition, they are providing computers and strengthening library capacity at the CHAM-affiliated institutions. NCA also conducts a twinning arrangement between all nurse training institutions and Universities in Norway, offering services of their faculty to teach for six-week periods in Malawi, and for Malawian nurses to be exposed to Norwegian Universities. The program also includes curriculum upgrading with an emphasis on learner-centered methods, moving away from the teacher-centered approach that has prevailed to date. Access to higher education is an important retention factor. Malawians place a high value on education. It confers status and provides opportunities for better employment, whether in Malawi or in another country. Several of the institutions offer opportunities for higher education. Another key concern is transportation. For those living on campus away from their primary homes, they need transportation to visit their families periodically, for major family events such as funerals, to shop, and to take their children to school. For those commuting, they need transportation from a common point to the school or between various clinical instruction sites. Although most schools provide some transportation assistance, it does not meet all of the needs. And, since schools are part of a large mission complex, which includes a hospital, the limited transportation that is available serves people in addition to tutors, including patients and students. Ministry of Health and CHAM leadership wants to do everything possible to attract and retain tutors to keep the institutions open and to produce more health workers, and they recognize the importance to tutors of both monetary and non-monetary incentives. They are concerned about what happens when funding for these incentives ends, as happened in 2005, with the resulting threatened work stoppage. Though they recognize that the nurse tutors have legitimate needs, they feel as though the tutors 11

15 have them over a barrel due to their scarce numbers and their ability to organize. The major concern of leadership is how to ensure ongoing funding when donor funding earmarked for that purpose runs out, as it did March 1, The solution to use a portion of the increased government-funded student scholarship for incentives holds some promise. However, CHAM realizes that it may not suffice over the medium term and has requested supplemental funding in its comprehensive plan 21. Both the MOH and bilateral aid agencies are concerned about continuing support for financial incentives. They worry both about the ongoing financial commitment monetary incentives require, but also about the impact on those health workers not receiving these incentives who may resent the special consideration given to nurse tutors. None of the respondents described a systematic approach to performance feedback. Where there is a performance evaluation system, it is not adapted to tutors. Some principals use student results on exams as a means of assessing tutor performance. They also speak with students to get their feedback on tutor performance and sit in on occasional classes. All acknowledged that they would like to institute a more systematic approach to providing feedback and recognize that it would be beneficial; however, in the absence of a career path for government-tutors, such a system would have little meaning. (See Annex F: Interview Notes) 4. Discussion and Perspectives 4.1 Facilitating factors Strategic human resource management and development There is a strategic approach to address staffing shortages and other HRH constraints. The tutor retention strategy was one of a number of strategies the MOH developed to improve the production, recruitment, and deployment of tutors in a comprehensive Six-year Emergency HR Program. In addition the MOH had effective intelligence and a sound evidence base to inform the development of an appropriate and effective mix of short term and long term strategies to address staff retention in general and nurse tutor retention in particular. Accurate and up-to-date information also enabled the health sector to develop selective and targeted retention strategies and to establish staffing requirements and training targets. Health sector commitment and leadership The health sector s Program of Work incorporates the HR plans and programs and key health partners and donors have demonstrated their support and commitment to their implementation. Public-private partnership CHAM is seen as a key partner in the delivery of health services in Malawi. It has developed a cooperative and collaborative relationship with the MOH in order to address tutor shortages. Its role as a key producer of essential health workers means that it can make a substantial contribution to addressing nurse shortages. Although the 21 CHAM Training Colleges Comprehensive Plan (2005) 12

16 relationship can be challenging at times and CHAM may be perceived as a competitor for scare human resources, the ongoing dialogue between the MOH and CHAM will help to improve joint collaboration to address the current HRH situation. Professional development Tutors have access to a mix of short and longer, more formal and accredited training opportunities to upgrade and improve their teaching skills and knowledge. Registered nurses with generic nursing degrees have access to scholarships to upgrade qualifications; the Kamuzu College of Nursing has developed a short course in teaching methodology by for assistant tutors; CHAM offers tutors scholarships for master degree programs and Norwegian Church Aid funds the exchange programs, exposing tutors to new instructional approaches and methodologies. Advocacy by CHAM and nurse tutors Both CHAM and individual nurse tutors are well organized and make sure their needs are heard. Nurse tutors are aware that training institutions would not be able to function without them and consequently training targets would not be achieved. CHAM has developed a five-year comprehensive expansion plan based on the institutions expansion plans. This plan addresses issues of infrastructure development, human resource management (recruitment, retention and development of academic staff), transport, teaching and learning materials and operational costs. In addition CHAM has managed to mobilize and secure substantial donor and government funding for its operations. Supply of tutors The provision of scholarships for degree programs in higher education has improved the production of nurse tutors. Effective institutional management Many of the training institutions have effective management systems in place. They are on track to achieve and exceed the planned training targets. They have produced business plans outlining their expansion plans and financial requirements. Tutor career structure CHAM has developed a career structure for tutors, which is helping to attract, motivate and retain staff. It has begun recruiting against this structure and has promoted some of its existing staff. Institutions are also recruiting locally, and there is evidence to suggest that those tutors are easier to retain where they are from the area and can live at home with their families. These tutors do not require staff housing, which is currently a very scarce resource. Infrastructure development The training institutions have secured funding from government and various donors to construct and expand teaching facilities and student and tutor housing. This infrastructure development will improve the institutions capacity to attract and retain tutors. 4.2 Constraints Student: tutor ratios 13

17 The 1:10 tutor to student ratio is difficult to achieve. Many of the training institutions are unable to achieve it and have ratios ranging from 1:12 to 1:20 or more. Even the best ratios are based on total numbers of staff. The reality is that tutors often have students in their classes at any one time. Attracting and retaining adequate numbers of clinical instructors and practice sites is also a major constraint to achieving the recommended nurse instructor/preceptor to student ratio of 1:5. Most of the training institutions are far from that ratio, ranging from the most optimistic estimate of 1:7 to 1:15 or more. Supply of nurse tutors In spite of efforts to increase the production and supply of nurse tutors, the numbers available are still inadequate to meet requirements. There is a lot of competition for degree nurses both internally from the private sector and NGOs, and externally from other countries. One of the difficulties is the length of time that it takes to produce nurse tutors. Many are registered nurses, who have already undergone four years of training, who need to be trained for a further two years to achieve the required qualifications. Because many of these are not electing to take the Nurse Education specialization, there is an inadequate supply of appropriately skilled tutors. The time taken to produce a tutor may take even longer due to the Medical Council s recommendation that tutors should have a Masters qualification. In addition, many of the nurse tutors are being taken from other areas of the health sector for upgrading training, which may lead to further imbalances in hospitals and in the lower health service delivery levels. Attracting and accepting registered nurses as nurse tutors may reduce the numbers taken from elsewhere in the system to meet tutor numbers. Supply is also constrained by inadequate infrastructure; KCN are interested in producing more graduates but it does not have sufficient infrastructure to do so. There is also an inadequate supply of clinical instructors, which has a negative impact on the quality of practical training. Many of the tutors are undertaking the role of clinical instructor, which is increasing their workload and may affect the quality of their classroom teaching. Shortages of tutors working as CHAM-affiliated staff Many of the institutions rely on government seconded tutors to meet staffing requirements; currently 65% of tutors are government seconded. Government seconded tutors fill many of the principal tutor positions, including that of College Principal. Because these tutors are often the most difficult to retain as they may only remain for the two-year bonding period, relying on them makes the nurse training institutions vulnerable to staffing shortages. Tutor career structure Although 65% of tutors are government employees, there is no official establishment within the government for the nurse tutor position. Many of those interviewed believed that the absence of a career pathway for tutors is contributing to the low numbers of trainees electing to undertake the BSc in Nurse Education and essentially devalues a career in education. Nurses perceive that the community health and management are more attractive career pathways. To be promoted within the health sector, one would probably have to leave teaching. Furthermore, the introduction of career structure for CHAM tutors may lead to greater dissatisfaction amongst government tutors who see their colleagues advance while they cannot, which could lead to increased shortages and attrition. 14

18 Lack of access to government benefits and opportunities While government tutors are seconded for the two-year bonding period to the CHAM training institutions their career are on hold, as they are neither eligible for promotion within the government system nor within the CHAM system. Tutors reported that they do not receive information on employment opportunities and have limited access to government training opportunities while they are with the training institutions. This situation is adding to their sense of isolation and creates the impression that they have been forgotten. It also reduces the likelihood that they will stay on in the training institution after the bonding period. Insufficient Housing Lack of housing is a major constraint in attracting and retaining staff. Institutions reported that they have had to turn away tutors because they do not have sufficient or adequate staff housing. This is reducing their ability to recruit tutors and preventing them from increasing their tutor numbers from the available supply. Some tutors are sharing housing, which they do not see as an appropriate solution to the problem in view of the tutors status and educational level. Weak monitoring of scholarships The government provides scholarships in order to improve tutor supply but there are no systems in place to follow up scholarship beneficiaries. Many students receive scholarship to undertake the BSc in Nurse Education but are electing to take alternative courses e.g. Community Health or Health Services Management. People attribute this situation to a number of factors such as: weak monitoring by the government; the perception that the Nurse Education program had a heavier workload than the other courses; and the fact that community health and management had more clearly defined career pathways and better employment opportunities. Kamuzu College of Nursing enrollment data indicate that of the 30 trainees who enrolled in 2005, only 6 are taking the Nurse Education program KCN Post-Basic BSc Enrollment 22 Total intake Nurse Education Community Health Health Management However, when they complete their studies all graduates are posted to the training institutions and bonded for two years as nurse tutors. Interviewees perceived that this was contributing to tutor shortages as some graduates were refusing to take up their posting. It was also having an negative impact on retention, as those who have not chosen the nurse education program are reported to have less interest in education; they are more likely to break their contracts or less likely to remain after the bonding period. It was also suggested that they may be less committed to the job and lack appropriate teaching skills, which may compromise the quality of their teaching. Tutor qualifications The focus on higher level training for tutors may result in prolonged absences of tutors from posts and contribute to staffing shortages. The qualifications recommended by the Medical Council may force more tutors to seek opportunities to upgrade their 22 Source: Dean of Nursing, Kamuzu College of Nursing. 15

19 qualifications. Upgrading training may not help bring increased staff into the health system; it removes tutors from teaching during training, and may reduce the likelihood of newly trained student returning to the training institutions. Upgrading tutor qualifications may also create greater disparity between tutors and clinical instructors, who generally have a diploma qualification and are at the lower end of the career structure. It may also make this group more challenging to attract and retain. Additional allowances Some institutions are more financially viable than others and are able to provide additional allowances and benefits to attract and retain tutors. This is resulting in disparity between institutions and may contribute to internal migration and inadequately staffed institutions in less attractive areas. Weak information systems There is limited consistent information available on retention and attrition trends to determine the effectiveness of the incentives in improving tutor retention. While this problem could be attributed to the IT problems CHAM has recently experienced, there is no evidence of a functioning monitoring and evaluation system or indicators to track impact and outcomes. Some institutions report that they have a performance management system but these are not functioning effectively. There is little evidence of systems in place to manage tutors time; to monitor the quantity and quality of their work; and to link training and development requirements to the needs of the job. There is no information made available on selection or promotion criteria and therefore it is unclear what informs these decisions. Focus on numbers/quantity The drive to increase enrollment and to meet national ratios may result in an overemphasis on quantity/ number crunching (of students, on staff, etc.) and less attention to quality and some of the softer HR issues. Some of the institutions are meeting national ratios based on the total numbers of staff; however some tutors reported that they are teaching classes of 40 students and above. The problem with staffing shortages goes beyond numbers and there needs to be robust human resource management and development systems to adequately address other HR issues, such as performance, productivity and motivation. Monetary incentives Monetary incentives are difficult to sustain and distort salary and compensation packages. Because of the publicity about tutor incentives, there may be resentment amongst other health workers that tutors are receiving preferential treatment. Those who are not receiving the incentives may be reluctant to support tutors/clinical instructors with responsibilities that would have, before the introduction of incentives, been undertaken jointly. Given the length of time tutors have been receiving the monetary incentives, they may now view them as an entitlement and therefore the incentives are no longer having the intended impact. It will therefore be challenging to withdraw them and/or to gain acceptance for replacing them with nonmonetary incentives. 4.3 Lessons learned Short-term versus long-term strategies 16