International development: 'Go and tell people what it's like here'

• Malawi's healthcare system struggles with too few nurses, inadequate resources and high disease rates.
• UK funding should see nurses' salaries increase by 52 per cent by 2010-11, but many seek overseas work as soon as they are qualified.
• Almost a million people are living with HIV and AIDS.

Until Madonna adopted a baby from Malawi, many people had not heard of this small, land-locked country in southern Africa. Often dubbed the 'warm heart of Africa', the young democracy has been largely spared the headline-grabbing conflicts and natural disasters of many of its neighbours.

Yet the challenges it faces are immense; the statistics heart-breaking.

The population trebled under Hastings Banda, Malawi's despotic ruler for three decades until 1994. As a result of his prohibition on contraception, the population now stands at about 13 million, 80 per cent of whom live in rural areas, mostly on subsistence farms. Half the people live below the poverty line.

The country has no significant mineral resources, little tourism and little infrastructure. Unemployment is 90 per cent and there is no access to clean and safe water for almost 40 per cent of the population.

Coupled with the grind of poverty is the ravage of HIV and AIDS. The figures are hard to comprehend. About 14 per cent of the adult population is infected and a million children have been orphaned by the disease.

Malawi's horrendous public health challenges are exacerbated by its chronic lack of healthcare workers: the numbers are low even by African standards and make NHS shortages look insignificant. Although training rates are improving, a question remains over how many will stay in Malawi once qualified.

The shockingly low salaries paid to public sector workers have long driven about half of all Malawian nurses to work overseas, particularly in the UK. The Malawian government also claims many nurses who have left are too old to work in Malawi, where the retirement age is 55.

Although the NHS has agreed to stop recruiting from the developing world, work is still available through private agencies; adverts for such opportunities can be seen in the Malawian press.

Malawian nurses are highly trained, but the system is old-fashioned, similar to the old UK system of enrolled and registered nurses. Although there are more of them and they often work unsupervised, nurse technicians are considered less able and are lower paid. They train for three years, as opposed to five for registered nurses, and both ranks are trained and work as midwives. Protectionism of the registered nurse status is strong and embedded.

Those healthcare workers who do stay in Malawi may be lured away from state jobs to work for non-governmental organisations providing healthcare or in the substantial private and charitable hospital sector. Almost 40 per cent of all healthcare in Malawi is provided by the umbrella organisation Christian Health Association of Malawi.

International assistance

Funding from the UK Department for International Development as part of the sector-wide approach programme is scheduled to continue to 2010-11, increasing nurses' salaries by 52 per cent.

DFID claims the pay increase has already led to improved retention, from 100 health workers a year being lost down to 25, although other sources dispute this.

The percentage pay increase sounds like a huge sum and HSJ's visit was expected to include meetings with nurses overjoyed with their good fortune. The reality was different.

Thoko Bema and his colleague Shadwick are nurses who work in the Chiradzulu district with an Oxfam HIV/AIDS and livelihood project, in Shadwick's case in his spare time from his work at Chiradzulu District Hospital. Their salaries have increased from about 19,000 kwacha to 35,000 kwacha (about£126) a month, but Mr Bema estimates that they would need to earn about 60,000 for it to constitute a living wage.

The pair graduated in 2001. Of their class of 46, half now work in the UK.

Other incentives to retain nurses are being considered, such as water and electricity provision for those who work in rural areas, or a fast-tracked career for remaining in those areas for three years. Nurses may get funding for their children's education although free, primary school education is not compulsory and families must pay for uniforms and food and contribute to the school's water and electricity bills.

Some of these measures may sound enticing, but nurses and lobbyists say that what would be most attractive is more pay and protective gloves for delivering babies - a simple request, but seemingly unachievable for the time being. HSJ's visit to the government-run Bwaila Hospital in the capital, Lilongwe, reveals the extent of the shortages of healthcare workers. But Oxfam advocacy manager Shenard Mazengera and Nurses' Association of Malawi executive director Dorothy Ngoma both confirm the situation is worse in more rural areas. 'Sometimes there are not even gloves. Nurses must put sugar bags on their hands,' says Ms Ngoma.

In rural clinics, a single nurse is often left in charge of more than 100 patients. They are expected to be on duty 24/7 and to work on every health issue that the local community has, from childbirth to road accidents. An average term of duty is five years and it is not unheard of for nurses to work in such conditions for 15.

Disturbingly, nurses are increasingly working 'pertroda'. Slang for petrol station, this means working a 24-hour shift. They either work consecutive shifts on different wards in a hospital or work in both government and private clinics. Doing 'locum' (overtime) on your days off is allowed; pertroda is supposed to be outlawed.

Lily, a nurse on the maternity ward at Bwaila Hospital, had arrived for work on Tuesday morning and did not expect to leave until Friday evening. She said her children were fending for themselves, but they kept ringing to tell her they had run out of sugar.

Another nurse, Filipina, looked shyly towards principal nurse Jen Chinsenga for permission to speak before saying she had done a night shift at the hospital's physical disability ward. It was now lunchtime and she was midway through a day shift on the maternity ward. Filipina says her elderly husband is too ill to work and she has five orphaned relatives and three grandchildren to provide for.

'I get my energy from God,' she replies when asked how she copes. But the nurses do not want charity: 'You go and tell people in your country what it is like here. That could help more,' says Lily.

Tackling maternal mortality

Malawi has the third highest maternal mortality rate in the world, after Afghanistan and Sierra Leone, with a rate of 984 deaths per 100,000 live births. To meet the UN's millennium development goals, this figure must be reduced by three-quarters by 2015, prompting a recent $2.2m World Health Organisation and European Commission pilot scheme to provide basic obstetric care in three Malawian districts. The key word is basic.

The reasons behind the horrifying statistics become clear when you hear the circumstances in which most women give birth.

Just over half of all births happen without a qualified birth attendant. Getting to a hospital, especially in rural areas, can be very difficult. Ambulances and ambulance motorbikes are rare even in cities, as are cars in remote areas. Bicycles are more common, and some villages have ambulance bikes but can only be accessed by dirt tracks that can be unusable in the rainy season.

So by the time a woman in labour reaches the hospital, it may be too late to stop her haemorrhaging, developing sepsis or high blood pressure, or to help the baby if it gets into difficulty. Conditions such as malaria and HIV/AIDS exacerbate poor health and complications.

Government care in Malawi is provided in regional health centres and district hospitals and there are larger so-called central hospitals in Blantyre - the country's biggest city and commercial capital - in the south and Lilongwe. In Lilongwe there are two: Kamuzu, a referral hospital which acts as a specialist centre, and the district hospital, Bwaila.

Bwaila's services are comparable with a cottage hospital, including a psychiatric ward, a physical disability ward and a large maternity unit.

Arriving at the 220-bed hospital, built in 1937, is like entering a village square. There are dozens of people, predominately women, with babies and children milling about. Many are waiting for lifts back home, others are sitting outside for fresh air.

Going into the maternity wards shows us why. On average up to 40 babies a day are born at Bwaila. There is a labour ward, an early-stage labour room, an operating theatre and a room for women with high blood pressure. A poster tells people nearby to be quiet.

Scarce resources

The maternity unit is sparse, with no equipment or computers. Lists of patients waiting for treatment are written on bits of paper. Everything is clean, but beds are squeezed into every spare inch of the two wards - one for women who have had Caesarean sections, the other for natural deliveries. Women are only allowed to stay on the wards for two days; if they need more care after that they must go to another hospital.

Babies stay with their mothers unless they are premature, when they may stay on the 'kangaroo care' unit, where the child is tied to its mother's body. There is also an intensive care unit, but there are none of the banks of machines and high staff levels commonly associated with that specialty.

The babies are two to a cot, partly because there are heat lamps above them and partly because there are not enough cots. Even those in 'boxes' (incubators) are not receiving oxygen. The two smallest babies weigh just 1kg each.

There is just one nurse, Felicitas, on duty in this area. She has worked in the maternity unit for 13 years and in intensive care for three. She likes working with these babies, she says, because it is good when they live.

We see where the babies are born. All labour wards are busy and harassed but the one at Bwaila is beyond hectic. At 10.45am we ask how many babies have been born since that day's shift started at 7.30am. The answer is six.

There are 14 labour beds. Principal nursing officer Jen Chinsenga says that when they run out of space women in labour must lie on the floor.

However, despite the lines of women feeding their babies or waiting for scans in corridors, the atmosphere is largely, incredibly, not hassled. The nurses look almost calm, perhaps down to a combination of resignation and exhaustion. Presumably, this is because the whole unit is chronically understaffed.

There are just two registered nurse midwives on duty on both the day and night shift and about 30 in total - that is, not per shift - on all the maternity areas, to cover the labour wards, high- and low-risk patients, post-surgery areas and theatre. Overall, the hospital has 51 nurses.

There are also seven clinical officers, who run units and rotate between Bwaila and Kamuzu hospitals.

There are shortages of basics such as protective wear, cord clamps, sutures, gloves and IV fluids. The lack of saline means its use is confined to theatre, but other wards need it too.

'Patients come very late from smaller hospitals or traditional birth attendants when there are problems,' says Ms Chinsenga, whose office keeps charts detailing maternal and infant death rates and causes of death.

There are no official targets on nurse recruitment, but Ms Chinsenga and her deputy, Modesta Kauduka, say that ideally they would have at least double the number, 60 nurses on the maternity unit and at least four or five registered nurses per shift in the labour ward. They are unsure if the DFID fund has made it easier to recruit, but have noticed that the number of nurses leaving has slowed down.

Ms Chinsenga has three children. Their combined school fees are more than her salary, even after the DFID increase, and she did not feel confident enough in her own hospital to give birth to her family there.

She speaks with a polite smile about the problems faced in the hospital, but the daily struggle is clearly getting too much. Later, she asks us about the possibility of getting a scholarship to study in the UK.

A million AIDS orphans

You are never allowed to forget about HIV and AIDS in Malawi.

Close to a million people have the virus, about 14 per cent of the adult population, and although the figure has begun to stabilise this is the eighth highest rate of infection in the world. Around a million children have been orphaned by AIDS, with 84,000 more being orphaned every year. Only a third of those infected have access to antiretroviral drugs.

Despite the prominence of HIV and AIDS campaigns - even bottles of mineral water bear a campaign logo - and condom advertisements lining roads, ignorance, fear and poverty mean stigma and risky behaviour continues.

Two per cent of all government budgets, both local and national, is supposed to be allocated to HIV and AIDS education and prevention programmes for staff. But public service wages are low enough for many to need a second income. For some this may mean working a small farm. For women it could mean prostitution, says Pontius Kalichero, general secretary of the Civil Servants' Trade Union.

The union's HIV and AIDS committee's work on distributing education leaflets and condoms, and similar work by the Malawi Municipal Workers' Union, have been funded by Unison. Both report that workers fear they could lose their jobs or be blocked from promotions and training if they disclose their HIV-positive status.

Workers also seek reassurance that they will be protected from discrimination if their status means they need to take sick leave, visit hospital or take time off to care for sick relatives.

Lack of access to equipment puts healthcare workers at particular risk. One nurse a week dies of AIDS, adding to huge recruitment problems. They are subject to discrimination, and being left untreated by their own colleagues who themselves fear infection.

A more advanced approach to HIV and AIDS care is in evidence at the Lighthouse project (no relation to the Terrence Higgins Trust scheme), which has centres at both Bwaila and Kamuzu hospitals, and four regional schemes.

Kamuzu's Lighthouse centre is worlds apart from the busy, chaotic hospitals. Funded by a variety of non-government organisations, the centre has a more professional and businesslike feel than the state-run hospitals.

The purpose-built building is clean, cool and calm, with modern equipment, heaps of free condoms in the reception area, a planted and lawned courtyard and a children's play area.

The centre offers HIV counselling, testing, daycare when clients need treatment such as rehydration, and home-based care. It also has a dispensary and a booth run by a support group, National Association for People Living with HIV/AIDS, which offers advice and sells nutritional and fortified foods.

Home-based care is carried out by an army of 300 volunteers, many of whom are clients, from around the district. Clients can pick which volunteer they want to work with from a folder containing their pictures and details of where they live.

A food supplement, Plumpy'nut, is given to clients. It must be prescribed as medicine, not food, says clinic manager Fred Chiputula. If it were given as food, then it would inevitably be shared out among the rest of the family.

The Lighthouse scheme sites now provide HIV testing and counselling for 2,000 clients a month. Of those, about 50 per cent are positive. Test results are available in 15 minutes and group counselling has been introduced to speed up testing numbers. Elsewhere in Malawian healthcare, roles are strictly delineated, but here every grade of nurse or doctor who is available carries out health checks, prescribes and gives out antiretroviral drugs about 250 clients a month are put on the drugs and provides daycare services for clients.

The centre also trains workers from across the country in HIV testing, counselling and dispensing antiretrovirals.

'We are so innovative here that we want to send this out at national level,' says Lighthouse director Enous Chang'ana.

Despite the advanced (by Malawian standards) and integrated practices carried out at the centre, stigma is still an issue. To reduce the number who do not attend for repeat visits, new clients are shown a map on which they point out where their village is located, and asked to fill out a form with details of any phones they may have access to.

But not everyone is intimidated by the stigma.

One of the home-based care volunteers is Esther, who wears an anti-Edzi (AIDS) T-shirt to work as a cleaner in the maternity unit at Bwaila Hospital, where she also teaches mothers breastfeeding techniques, earning 5,000 kwacha a month. She is infected, and her husband died of the virus.

'I am not ashamed,' she says.

Workforce: tackling the recruitment crisis

With half the population not living within 5km of a health facility, traditional healers and birth attendants are relied on for much healthcare in Malawi.

Conventional health worker vacancy rates stand at about 50 per cent. There are now 700 health workers, of whom 560 are registered nurses.

There are fewer than two doctors and 29 nurses per 100,000 people, or 124 doctors for the entire country. There are just four pharmacists in Malawi.

The UK Department for International Development is looking for 8,000 health workers to be in place by 2010-2011. The number of nurses needs to be doubled and doctors trebled. It believes that training targets are being exceeded, with improvements for both doctors and nurse training numbers.

By April, 450 workers had joined the system. Numbers are under review but it is understood about 50 registered nurses and up to 350 nurse technicians a year are now being produced.

A country in turmoil: facts and figures

• Malawi is one of the 10 poorest countries in the world.
• Over half the population lives below the poverty line.
• The average income is£80 a year.
• Unemployment stands at about 90 per cent.
• Just 66 per cent of the population has access to clean water.
• The diet of 22 per cent of people does not meet their nutritional requirements.
• Average life expectancy is now 37 years. It has fallen significantly in the past 20 years.
• Out of every 1,000 children, 133 die before their fifth birthday, but this is 40 per cent down from 2005.

Find out more

See the opinion section of HSJ online for a diary of Emma Dent's trip to Malawi

Department for International Development's country overview for Malawi

Unison international HIV/AIDS campaign

Oxfam's Malawi programme