PUB - Publikationen an der Universität Bielefeld

Background: At the beginning of the new millennium, Malawi receives international attention for its Human Resources for Health (HRH) crisis, together with 57 other developing countries identified in the World Health Report 2006. Poverty-related diseases including HIV/AIDS have added to the workload and perpetuated attrition from the Malawian health workforce. After president H.K. Banda’s 30 years of autocratic rule ended in 1994, the health labour market has also become increasingly international. Opportunities have opened up to find work and better payment either abroad or with private and non-governmental organisations. By 2009, a large-scale intervention of international donors is underway to re-strengthen HRH as a basis for delivering an essential health package to the Malawian population and reducing poverty. Starting from the idea of sustainable development that has evolved since the Rio Declaration 1994, the underlying assumption of this study is that qualified health work can be seen as a common-pool resource system. Commons theory suggests that self-organization and rule-setting by relevant actors could help to balance the appropriation and (re)production of a resource in a circumscribed system. This study investigates how the cooperation of Malawian and international employers can be regulated to achieve a well-performing and sustainable health workforce. Methodology: Malawi has been selected as the research site for a country case study based on qualitative and quantitative, primary and secondary data. A field research phase of six months in 2009 has been used for collecting text documents and statistics, and for conducting 25 expert interviews. Secondary data has been analysed to reconstruct the historically grown structures and conditions of HRH and international cooperation. Interview data has first been subjected to thematic analysis, with themes deducted from the UNDP capacity development framework. Relevant findings feed into an institutional analysis (Oakerson 2003; Ostrom 2005), looking at strategies, norms and rules applied to HRH in Malawi. The focus is on the district health system as an action arena, but other linked arenas are also considered. Results: The HRH system in Malawi shows warning signs of depletion, as reproduction through training cannot meet the domestic demand and compensate for attrition. Expectations to revert this trend are focused on the government and the Christian Health Association of Malawi (CHAM) as those who have historically been in charge of securing the availability of different cadres of health workers. At the same time, the appropriators of HRH (organisations acting as employers or contractors) have multiplied and diversified. This group is characterized by striking asymmetries regarding their dependence on HRH, their financial and technological endowments and their autonomy in decision making. International actors’ entry to and exit from the system is weakly regulated. As for the level of the health district, three basic strategies of international aid agencies emerge: (1) direct implementation of health-related activities, (2) implementation through the District Health Office as a governmental structure, (3) implementation through other Malawian organisations or consultants. Although HRH is a cross-cutting issue in health service provision, the interview statements hardly convey explicit rules concerning the inter-organisational cooperation on HRH appropriation and/or reproduction. Concepts of staff supervision and professional development continue to be geared towards control and hierarchy. Even when it comes to the zonal or national level, the special features of HRH - such as individual decision-making and mobility of health workers, their socio-cultural embeddedness and their capacity to organize – only begin to be addressed. Discussion: Human resources largely meet the economic attributes of a common-pool resource, namely subtractability, indivisibility and limited excludability. As such, it appears promising to apply governance concepts to HRH which have originally been devised for sustaining natural resources. However, compared against the sustainability criteria named in commons theory, the findings for Malawi (together with the political developments since 2009) do not give rise to optimism. New forms of governance in this field are likely to be inhibited by the degree of deterioration of the HRH system and the existing incentive structures, the difficulties of monitoring, a lack of trust and reciprocity among the different actors and low levels of autonomy from external forces. At the same time, the study has revealed some potential points of intervention if collective rule setting at the level of the health district is to be enabled, involving local and global, governmental and non-governmental actors. Political decentralisation appears to have reached a new phase in Malawi, with the local elections finally conducted in 2014. The district assemblies and the Zonal Health Support Offices may take responsibilities with regard to monitoring and conflict resolution in the HRH system. The increasing frequency of strikes among health workers also underlines the need for clearer regulative frameworks at the constitutional level in Malawi, providing for new actor constellations and a new understanding of HRH.