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Investing in the workforce: The Malamulo scholarship initiative to improve retention of health workers in Thyolo District, a rural district in Malawi. Katharina Hermann¹, Amanda Banda ¹, Joe Kalilangwe², Andrew Likaka², Carol Metcalf 3 , Edwin Nkhono², Paul Moyo 4

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Investing in the workforce: The Malamulo scholarship initiative to improve retention of health workers in Thyolo District, a rural district in Malawi

Katharina Hermann¹, Amanda Banda¹, Joe Kalilangwe², Andrew Likaka², Carol Metcalf3, Edwin Nkhono², Paul Moyo4

¹ Médecins Sans Frontières, Thyolo, Malawi; ² Ministry of Health, Thyolo District, Malawi; 3 Médecins Sans Frontières, Cape Town, South Africa; 4 Malamulo College of Health Sciences, Thyolo, Malawi

  • Background
  • Malawi has 2.3 doctors and 36.8 nurses per 100,000 population, considerably below World Health Organization (WHO) recommendations (Table 1)
  • Table 1: Health workers per 100,000 population
  • Urban: rural imbalance: 30% of the health care workers work in rural areas where 70% of the population live
  • Thyolo District, a rural district in southern Malawi, has one of the lowest number of health workers per capita population of all districts in Malawi
  • WHO 2010 policy recommendations: Students from rural backgrounds 2 to 3 times more likely to work in rural areas than those from urban backgrounds, with targeted admission policies having a significant long term impact
  • 2010 Malamulo Scholarship initiative by Médecins Sans Frontières (MSF) and the Ministry of Health (MOH) to train mid-level health workers at Malamulo College in Thyolo District; scholarship covers tuition fees and accommodation

"When I was 15 years [old], my sister fell sick and we took her to Thekerani hospital. The queue was so long and there was only one clinician. We arrived at 7 am and my sister died right there in the queue at 2:00 pm, it was very difficult to understand. The death of my sister was due to the shortage of health care workers and I decided to become one."

One of the Malamulo students

  • Results
  • Of 204 applicants, 80 met minimum entry requirements of Malamulo College of Health Sciences
  • 30 scholarships awarded: 13 nurse-midwives, 10 medical assistants, 5 clinical officers, and 2 laboratory technicians (Figure 1)
  • Mean age on entering programme 22 years; 20/30 (67%) male
  • Students will graduate between 2013 and 2015
  • Majority stated that they would continue to work in a rural area after satisfying bonding requirement
  • Student concerns: (1) career advancement & lack of opportunity to upgrade qualifications during bonding period; and (2) harsh living conditions in the rural areas

WHO 2010 policy recommendations

Education: Use targeted admission policies to enrol students with a rural background in education programmes for various health disciplines, in order to increase the likelihood of graduates choosing to practice in rural areas.

Regulatory interventions: Provide scholarships, bursaries or other education subsidies with enforceable agreements of return of service in rural or remote areas to increase recruitment of health workers in these areas.

“There are so many patients here to see... sometimes people wait for hours to be attended to. Yesterday I was alone on duty without even an MA [Medical Assistant] to help me. Sometimes I have to do both day and night shifts in the same day! We need at least five more nurses here.”

Figure 1. Expected year of deployment by cadre

  • Conclusions
  • Scholarship initiative will reduce, but not fully address, health worker shortages in Thyolo District
  • Success of the scholarship initiative not yet known: Can only be evaluated several years after graduation
  • Unknown whether scholarship recipients will continue to work in rural areas long-term, despite their professed willingness to do so
  • References
  • 1. DFID, MSH, and MSC. Evaluation of Malawi's Emergency Human Resources Programme. Lilongwe: MSH; 2010.
  • 2. WHO. Increasing access to health workers in remote and rural areas through improved retention. Global Policy Recommendations. Geneva: WHO; 2010.
  • Methods
  • Needs assessment to identify types of health workers needed most and geographic areas with the greatest shortages
  • Scholarships awarded to students from rural areas, prioritising those from remote areas with the most severe staff shortages
  • Enforceable bonding agreements to work in rural health facilities in Thyolo District for at least 5 years after graduation
  • Regular contact with scholarship recipients to provide mentoring & support
  • Database developed to keep track of scholarship recipients with follow-up to be continued after graduation
  • Village chiefs and traditional authorities involved in the recruitment process
  • Recipients completed a brief questionnaire on entering programme

CONTACT:Amanda Banda, Email:, Phone: + 265 1 844 409, Website: