NURSING AND MIDWIFERY

85 medical doctors, whose training is comparatively expensive³⁶. At the same time, however, the government of Malawi made a formal request to the WHO to send an expert mission and explore the feasibility of establishing a medical school. The underlying argument was that the health infrastructure had been greatly scaled up, but doctors trained abroad had difficulties to adapt to the conditions in rural Malawi and were often lost to the health services³⁷. Medical officers deployed in district hospitals were expected to work on their own, covering a wide range of specialties and supervising the health facilities in the district, without much supervisory support from headquarters or central hospitals³⁸.

86 The CHAM training institutions train nurses up to technician level (2 years) or diploma level, hence they are also said to have a central role in the efforts to scale up staffing in the health sector. They are coordinated through the training board and follow joint curricula. Funding for operating costs such as salaries, accommodation, transport and student fees is provided by government, and the targets set by the MoH require CHAM colleges to at least double their student intake. However, problems are reported for the necessary investments in infrastructure as well as the staff motivation and availability of tutors. Due to specific funding arrangements, incentives to supplement salaries are not provided for, and overall donor funding is considered insufficient⁴¹. Nurses constitute the largest group among the qualified health workers providing personal health care. According to Annex 7.7.1, there were 2,932 nurses/midwives and 968 nurse technicians working in Malawian health facilities in 2008. 37.79% of the nurse/midwives work in urban, 33.15% in rural and 29.06% in semi-urban areas.

Among the nurse technicians, the share of those deployed in rural health facilities was highest (39.57%). As in most countries, the gender balance is very uneven, with 91.51%

female vs. 8.49% male nurses/midwives (see Annex 7.7.2).

History of nursing and midwifery in Malawi

The first nurse training initiatives are reported from the missions in Malawi at the beginning of the 20th century. The Livingstonia mission pleaded for a national register of trained Nurses and Midwives, along with Medical Assistants, in the year 1914 already. Nurse trainings in several rural hospitals were started in the 1920s and were registered by the Medical Council since 1926. The first governmental medical training institution opened in Zomba in 1936 and provided training in nursing besides other health occupations⁴².

Midwifery is conceptualised as an additional qualification after basic nurse training. A Midwifes Ordinance Board was introduced in 1947 and established the first midwifery courses, taught in English language. In 1966 a separate council for nurses and midwifes was founded, which coincided with the opening of the National School of Nursing in

41 MoH, SWAP Donor Group, GTZ (2007)

42King, King (2007)

87 Blantyre in 1965. The latter aimed at incorporating the sciences into nurse teaching and thus had higher entry requirements (General Certificate of Education) than previously established auxiliary training courses. It was expected that these nurses would be leaders in the provision of comprehensive nursing care in rural and urban settings⁴³. The higher entry requirements were also supposed to lay the foundation for clinical specialisation at academic level⁴⁴. At that time, more than 100 nursing students were still accomplishing their training abroad⁴⁵.

In 1979, the school was moved to Lilongwe and - under the name of Kamuzu College of Nursing - became a constituent college of the University of Malawi⁴⁶. From 1980 onwards, different one-year specialisation courses were offered, including Public Health Nursing⁴⁷. Public Health aspects and health education had already been introduced to the nursing curricula with the opening of a school for community nursing in Zomba in 1969, which was assisted by the WHO and had a focus on maternal and child health. However, resistance in the MoH against a separate cadre of community nurses led to the creation of the ‘comprehensive nurse’, who was supposed to be flexibly deployable in both urban hospitals and rural communities. Public Health thus became part of general nursing and of midwifery courses⁴⁸. Hence the PHC discourse was embraced by officials of the profession as being well suitable to the philosophy of nursing and offering a chance to comprehensive and autonomous professional practice⁴⁹. At the beginning of the 1990s, however, it was deplored that graduates of the college were still mostly being deployed in medical-surgical settings rather than in the community⁵⁰. Moreover, 18 years after the introduction of the Bachelor degree in nursing, a study from 2008 finds that graduates are usually employed as matrons or

43 Sagawa S (1982) History of Nursing in Malawi (Vol. 9). Medical Quaterly, 9: 26–27

44 Sagawa (1982)

45King, King (2007)

46Chigwenembe S S (1982) Courses Present and Projected for Training Manpower: In: The 1982 Papers presented by Heads of Sections Meetings held at the Headquarters in Lilongwe, Malawi from January to December 1982. pp. 10–16

47 Sagawa (1982)

48Mackintosh A (1971) A Comprehensive Nurse (Vol. 3). Moyo, 3(3): 4–7; Zindawa, A. B. (1975). The National School of Nursing (Vol. 7). Moyo, 7(4): 6–11.

49Mwale T (1985) The role of the Nurse/Midwife in Primary Health Care. Medical Quaterly,: 48–49.

50Banda, Chimango (1993)

88 ward sisters in-charge. As such, they are facing a high administrative workload while often having little work experience⁵¹.

In terms of professionalisation, the Nurses and Midwifes Act of 1966 marked another important step, whereby registration was separated from the medical profession. The Nurses and Midwives Council of Malawi was established as a regulatory body, which is also in charge of overseeing continued professionals development (CPD) for nurses ⁵². Less formal CPD among nurses is mostly occurring through workplace activities (handover meetings, workshops), while the access to professional journals or to the internet is low⁵³. As a professional association, the National Organisation of Nurses and Midwives of Malawi (NONM) was founded in 1979. It is a member of Public Services International and claims the functions of a nursing-specific trade union.