Participant characteristics and their career intentions are summarised in Table
. Specific specialty choice has been omitted where we felt it could identify participants.
Summary of participants’ career intentions
Intentions for Future Employment
All participants said they would like to study/work abroad for some time and then return to work in Malawi. Most thought they would work for the government for the foreseeable future. Although three students had considered practicing privately in the future, all interns wanted to work for the government. No participant expressed an interest in working for NGOs or any private sector organisations.
All participants wanted to undertake postgraduate training to specialise in the future. Three of the four graduates would prefer to start postgraduate training as soon as possible, rather than spending time working in government district hospitals first. Conversely, seven of the eight students said they would rather get experience working in district hospitals before specialising.
Overall perception of current doctor emigration
Amongst students, graduates and staff, there was a feeling that emigration is less of a problem in Malawi now than it has been previously, and although some doctors will still leave, more are returning from postgraduate studies abroad: “Nowadays people are getting a different mentality and they want to work in their home country” (student). Some participants thought the same numbers of doctors were emigrating, but “because we have improved on the numbers [of doctors graduating] we think that it’s not a lot of doctors that are going out” (graduate). A number of students also commented on the fact that there are supposed to be more doctors in Malawi now, but “you still find that in some district hospitals you don’t have enough doctors. And you wonder, where did all those people go to?” (student). Participants thought most of their peers would leave for postgraduate training and then return to work in Malawi, and graduates noted of doctors who had gone abroad to specialise, “most of them, I see them come back” (graduate). Amongst all respondents, the main reason cited for doctors leaving Malawi was the possibility of higher salaries abroad, which could better support their families or pay them through specialist training: “After I graduate I will want to earn a good living so I can help my family out…here in Malawi our doctors earn a lot of money but you can’t compare it to the way you can earn money outside Malawi” (student).
Other reasons given for emigration include feeling disillusioned at being unable to use specialist skills due to lack of resources (“they might want to come back but maybe the specialty they did is not available here, and it’s difficult for them to contribute, so they may just opt to stay” – graduate); perception of doctors still not being sufficiently rewarded (“It’s improving but not the way it’s supposed to be like” – student); becoming accustomed to better conditions abroad and therefore feeling unsatisfied in Malawi, and being stuck working in a remote district hospital. A number of explanations were given for why fewer doctors are now emigrating. The first is remuneration – doctors’ salaries in Malawi have increased, and the government are offering newly graduated doctors “positions of authority and also I’d say finances as well” (student) in district hospitals. Other explanations were as follows: perception of stricter immigration rules for health professionals in the UK; sending students to South Africa for postgraduate training where their visa will not allow them to work afterwards; as there are few specialists in Malawi, “if we say we will specialise it means we have a good chance of employment” (student); doctors are now trained within Malawi and therefore have less links abroad; and “the magnet effect… when people were going away everybody wanted to go away, but now that people have seen people coming back and living quite comfortably, then they say, ok, if they have done it, then I can possibly do it too” (lecturer, COM).
Factors affecting emigration choices
All participating students and graduates intended to work in Malawi eventually, however all also intended to spend time studying (eleven participants) or working (one participant) abroad first. Reasons participants gave for wanting to study or work abroad were centred around experience and exposure to a different health system and more advanced equipment, and in order to bring back valuable skills to Malawi: “I would maybe work for some years in a certain country just to see how things are, like maybe what the health system is like, but eventually I will come back to my country” (graduate). It was also recognised that training in certain specialties cannot be provided in Malawi and necessitated time overseas: “I would like to work in Malawi. I’ve never thought really about working in another country. I would love to work in Malawi but if I want to specialise in [medicine subspecialty] or [medicine subspecialty] then you always have to go abroad just to specialise and then you come back here to work” (student).
Reasons participants gave for wanting to return to work in Malawi were a desire to increase the number of doctors, patriotism and a love for their country, and recognition of Malawi’s significant health needs leading to an aspiration to “help my people” (student).
Factors affecting urban/district working
The most common reason given by participants for working in an urban area is a desire to specialise, and therefore an assumption that afterwards “you have to work at a very big hospital” (student). Even those who expressed a desire to work at district level (i.e. in a district hospital) thought it unlikely they would be able to after they had specialised: “It depends on the resources, because I can say I can work in the district hospital but are there theatres there? I may not be efficient to the community because I’m just there but I don’t have the resources to work with” (student).
Poor living conditions and services, and frustration with lack of resources at district level were reasons to stay urban, as well as learning opportunities and exposure to complex cases at central hospitals: “At [QECH] there are a lot of consultants, so you get to learn more…as well as exposure to some of the conditions which you will not have in any other hospital” (student).
Almost all the students and two of the graduates expressed an interest in working at district level for some time. The main reasons were to “associate with people in the districts”(student), to get experience of cases which don’t usually reach central hospital, and in order to be eligible for government postgraduate funding (“people are assured that after working for the government for a while, they’ll get their scholarships” - graduate). Two students expressed a desire to improve health in the districts their families came from: “You have this passion you know; this is where I come from, and you want to improve things with all your might” (student). Others include: increasing the number of doctors in the districts and improving rural health; personal development (“you get mature because you’re managing the whole hospital by yourself” - graduate); exposure to administration and hospital management; and the fact that district posts are now relatively well paid and “more like a top position in government” (graduate). Most participants agreed doctors should spend some time working at district level once they finished medical school, because “the government is spending a lot to produce doctors…we should pay back by helping those people” (student). However, two participants thought “everybody must have the freedom to do what they want” (student) after their internship, and thought it was the government’s responsibility to encourage doctors to work in those areas: “The government funded them that’s true. But the working conditions shouldn’t be that bad so that somebody shouldn’t enjoy the rest of their career” (student).
Challenges associated with working at district level were the “huge workload” and “the challenge that everyone else will be looking up to you and say, we need a decision from you” (graduate). Other difficulties included the focus on administration duties over clinical practice; the maldistribution of staff and resources leading to posts in some districts being more challenging than others (“there are other districts which are very far and there aren’t good resources and the houses are not proper houses” – student); the fact that “In most districts there are not good opportunities to work in a private hospital” (student); and poor housing and living conditions.
Reasons given by participants who expressed an interest in working at district level after specialising focused on improving rural health by increasing the number of doctors at district level. One participant mentioned being from a rural area as a key motivation for working at district level (“I’ve seen how people struggle here, and I’ve struggled once in my life and there has to be a change somehow” – student); another mentioned the challenging environment as a motivating factor. These are participants who want to undertake postgraduate study and therefore, although motivated, believe they will be unable to work at district level afterwards due to lack of equipment.
Most staff thought that new posts at district level were encouraging doctors to continue working in the districts, due to improved salaries and the opportunity to make extra money from per diems given for meetings attended as senior MoH staff. Even so, it was thought once they married they would also want to move to cities (“their children should go to good schools” - lecturer).
Factors affecting public/private sector working
There was no difference between students and graduates in their perceptions of the private sector, but one graduate suggested “the problems we face as doctors…so many responsibilities, you want to support your family, and you’re not getting enough money”, led many to practise privately. Most participants thought they would work for the government, at least initially, due to better postgraduate training opportunities, and discussion arose about doctors working in the public and private sectors simultaneously, or starting in the public sector and moving to the private sector once specialised: “I will practise in public, so in the government. But maybe I will also be having my own clinic somewhere, for sure” (student). Participants were not interested in working for NGOs as it was considered not to be a “long term career opportunity” (graduate). Some participants thought CHAM posts were better paid than government positions, and mentioned postgraduate training and better funded hospitals in CHAM as attractions; others thought the new government district posts were better paid. There seemed to be a perception amongst participants of being better looked after when working for the government than in the private/NGO sector.
Amongst staff, opinion was divided as to whether private practice, NGOs and CHAM were draining doctors from the public sector or not – some perceived it to be a “big drain”, others stressed that the private sector in Malawi was very small and therefore not employing many doctors, and that training opportunities were better with the government. A senior lecturer at COM noted “the Malawi thinking is that if you end up working in private sector but still in Malawi, you’re not really a loss to the nation because you’re still serving Malawians.” It was acknowledged that due to low pay, many senior staff at COM and QECH engage in dual practice, and that switching between public and private practice was frequent: “it’s not rigid, people change” (lecturer).
Factors affecting postgraduate specialisation
All participants wanted to specialise in the future. The main reason given for wanting to specialise was ‘upgrading’; almost all participants wanted to further their education and not stay at a generalist level. The medical degree was seen as a ‘first degree’ which needed ‘upgrading’ for career progression. “It doesn’t make sense just to stay on the same level. I think it’s not even recommended for doctors just to stay on the same level. You need to do some upgrading” (student).
This aspiration to specialise often curtailed time working at district level, “you might want to work in the district hospitals but then at a certain point in time you would want to specialise” (student), and for four participants took priority over a preference for district work (Table
Other reasons for specialising were to provide better care to patients (“You need to specialise, get yourself attached to one field. In so doing you can provide better treatment to the patients that you see” – graduate) and improved work satisfaction: (“If you are someone who has specialised, I think Malawi is a better environment to work in. Why? We tend to see lots of patients here so you would find your work interesting. You wouldn’t get bored. There are always customers” – graduate). Two students were motivated by being one of very few specialists in their field, and one explained they would like to inspire others to go into that field. “I think it’s an exciting prospect to be among the very few. Maybe if I will become a neurologist, I would inspire other people who would maybe also want to be a neurologist” – student. Interestingly, none of the graduates mentioned a lack of specialists in their chosen field as a motivation.
A major concern for all participants, but particularly graduates, was procuring funding for postgraduate study. “There is such a long waiting list. It depends how much patience you have and resilience. Some people would just stop [searching for a scholarship]” (student). All graduates were anxious about the limited number of government scholarships available. “There a lot of people right now in the department who are registrars who wants to go to school, but because the government doesn’t have enough money, then they are in like a queue, they send only like two people, one or two at a time, so I think it’s quite difficult.” (student). Three graduates intended to look for private scholarships so they could specialise as soon as possible, rather than working at the district level for two years. “If I had other options of like getting a better job, securing money so that I can sponsor myself, I would have grabbed such an opportunity” (graduate). Reasons included a desire to complete postgraduate training whilst they have few other commitments (“Right now I’m not married, so before I get too involved with that I want to do postgraduate training” - graduate) and a sentiment that further training was easier to undertake whilst still young and “the brain is fresh” (graduate). One graduate stated that he was considering emigrating to earn enough money to fund himself through postgraduate study, if he was unable to secure a scholarship: “I would love to stay in Malawi. But am I going to secure a scholarship? That’s the main worry”.
All participants had a clear idea of their intended specialty. The choice of specialty, for many participants, was based upon role models amongst doctors practising in Malawi: “Our consultants are like our role models - that would be one of the things which encourages people into what specialty they want to go” (student). This visibility is reflected in the range of intended specialties, with the major specialties of internal medicine, surgery and obstetrics and gynaecology well represented but few subspecialties selected (Table
). Participants also mentioned the burden of disease in Malawi as a factor in their choice: “I just have this idea that it’s good to put effort where it’s needed most. If there’s an area which needs a lot of effort in Malawi, it’s obs and gynae.” (student). However, both students and graduates were aware that the government had moved towards a policy of training more subspecialties in underrepresented fields: “So far, most of the doctors that had trained previously, they were doing things like general medicine, surgery, paediatrics, obs and gynae, but now they are more oriented on other specialties which haven’t been covered so far” (graduate). Despite this policy shift, only one participant recognised that s/he may not be able to train in their first choice specialty: “For example, the government has said there is an oncology scholarship, you never planned on doing oncology, but since you can’t secure a scholarship in an area of your interest you are forced to pick something which is different all together.” (graduate). Two staff members felt that it was useless to train specialists in certain fields if the required equipment was unavailable in country for them to practise afterwards, e.g. radiotherapy for oncologists. One member of staff commented on the need for recognised postgraduate training in family medicine/general practice, so doctors felt they were furthering their education but could then practise general medicine. All staff agreed that career advice and guidance was lacking for students and graduates at present, but that this situation should improve as more specialists return to Malawi from training abroad.