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Background: Malawi faces a severe shortage of health workers, a factor that has contributed greatly to high maternal mortality in the country. Most clinical care is performed by mid-level providers (MLPs). While utilization of these cadres in providing health care is a solution to the current shortages, demotivating factors within the Malawian health system are pushing them into private, non-governmental, and other non-health related positions. This study aims to highlight these demotivating factors by exploring the critical aspects that influence MLPs’ intention to leave their jobs.Methods: This descriptive qualitative study formed part of the larger Health Systems Strengthening for Equity (HSSE) study. Data presented in this paper were collected in Malawi using the Critical Incident Analysis tool. Participants were asked to narrate an incident that had happened during the past three months which had made them seriously consider leaving their job. Data were subjected to thematic analysis using NVivo 8 software.Results: Of the 84 respondents who participated in a Critical Incident Analysis interview, 58 respondents (69%) indicated they had experienced a demotivating incident in the previous three months that had made them seriously consider leaving their job. The most commonly cited critical factors were being treated unfairly or with disrespect, lack of recognition of their efforts, delays and inconsistencies in salary payments, lack of transparent processes and criteria for upgrading or promotion, and death of patients.Conclusion: Staff motivation and an enabling environment are crucial factors for retaining MLPs in the Malawian health system. This study revealed key ‘tipping points’ that drive staff to seriously consider leaving their jobs. Many of the factors underlying these critical incidents can be addressed by improved management practices and the introduction of fair and transparent policies. Managers need to be trained and equipped with effective managerial skills and staff should have access to equal opportunities for upgrading and promotion. There is need for continuous effort to mobilize the resources needed to fill gaps in basic equipment, supplies, and medicine, as these are critical in creating an enabling environment for MLPs. © 2014 Chimwaza et al.; licensee BioMed Central Ltd.
This qualitative exploratory study was part of the larger Health Systems Strengthening for Equity (HSSE) study. The HSSE study aimed to expand the evidence base on effective use of mid-level health workers in EmOC. Data for this element of the study were collected through anonymous Critical Incident Analysis interviews. Critical incidents are incidents or events that are critical to the person’s view of a particular phenomenon or problem. This is a technique that is commonly used for collecting incidents that the respondent feels have been critical to his or her experience of a job [15]. Once the incident has been recorded the interviewer uses probing questions to elicit the details of the incident and the respondent’s reactions and feelings about the incident. Incidents that caused the health worker to consider leaving the job can be explored in this way in order to identify factors that are critical to health workers’ decisions on whether to leave or remain in a particular employment. Data for the broader HSSE study were collected in 25 of Malawi’s 28 districts. Eighty-eight health facilities providing EmOC were visited. All types of facility were included: government district hospitals; Christian Health Association of Malawi (CHAM) health facilities; and health centers providing EmOC. To avoid overburdening health workers, three districts (10 facilities) that had recently taken part in another Human Resources for Health study were excluded. An information circular was sent to facility managers detailing the project and they were contacted one week to 10 days later for their decision on participation. When a positive response was received the research team visited the facility. In each facility teams first introduced themselves and the study to the facility and/or maternity in-charge. They inquired about the number of staff currently working in the maternity unit, as well as any staff who might have temporarily been assigned to another unit (for example, the outpatient department or the reproductive child health unit). The maternity and/or facility in-charges also helped to identify the clinical staff (that is, doctors, clinical officers, and medical assistants) who are called for emergency procedures, such as cesarean sections. Teams recorded the number of staff in each cadre to ensure that there would be adequate representation of each cadre in the total sample. All relevant health workers in the selected facilities were given a Participant Information Leaflet detailing the nature of the project and their possible involvement during the data collection process. A member of the research team was always on site to answer any questions about the project during the two days allocated for each site. The eligibility criteria for the broader HSSE study required all participants to have performed at least one of the EmOC signal functionsa in the three months prior to the study, so prospective participants indicated which ones they had performed using a list shown to them by the data collectors. A total of 631 health workers took part in the main data collection. A purposive sample was used to identify a subset of these health workers for the Critical Incident study. To be eligible for this element they had to respond positively when asked if they had experienced a specific incident at work that caused them to become demotivated or even to think about leaving their job, and be prepared to describe this incident in an interview. When the research team was satisfied that staff fully understood the nature of the project and what was required of them, and that they were both willing and eligible to continue, staff were asked to provide written consent. Data collection took place from October to December 2008. The research team included three experienced qualitative interviewers and two clinical officers who had all been trained in the study and its methodology prior to data collection. They were asked to interview one participant in each facility and to try to target all cadres providing EmOC. To ensure good participation and response, the interviewers had to be sensitive to the prospective interviewee’s work schedule, be flexible with regards to interview time, and use a private, quiet place for the interview. A total of 84 interviews were carried out, all of which happened to be with MLPs. The interviews were recorded and transcribed by the interviewers. Most were in English, but a few were in Chichewa (the most common local language spoken in Malawi) because the interviewees felt more comfortable conversing in Chichewa. The Chichewa interviews were transcribed in Chichewa by the interviewers and later translated into English by researchers proficient in both languages. The transcripts were later imported into an NVivo 8 software database for thematic analysis. Data analysis was carried out by three researchers from the College of Medicine in Malawi (WC, EC, and AN) and a qualitative researcher in Ireland (SB). A coding template, based on the literature and discussions about the data, was developed. All four researchers spent one week together in Malawi to perform the initial coding face-to-face, discuss emerging themes, and validate their coding. Further analysis was carried out by the team in Malawi, with additional input from SB. The coding framework was revised as new nodes emerged. These were clustered into relevant top-level themes, then a process of synthesis was used to draw out key findings and themes. The study was approved by the Institutional Review Boards of Columbia University, New York and the College of Medicine, Malawi; and by the Global Health Ethics Committee, Trinity College, Dublin.
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