Protecting the public versus tackling human resource for health deficit

In Malawi, where the healthcare system frequently makes headlines for its shortages of drugs and medical workers; Owen Nyaka of Nyasa  Times investigate an existing gap that contributes to human resource for health deficit.

Malawi has produced less than 10,000 nurse and midwives; according to Nurses and Midwives Council fact sheet – yet the country’s population has almost quadrupled since then.

In the financial year 2012 to 2013, Ministry of Health estimated that Malawi had a vacancy rate of 91% for medical specialists, 85% for pharmacy staff, 69% for nursing staff, 31% for medical doctors and 61% for allied health clinical staff.

Malawi, just like most sub-Saharan countries in Africa is facing a crisis in human health resources due to critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals, difficult working conditions and low motivation.

However, despite these regional challenges, Malawi has its own unique challenge called, ‘licensure exams’ which some quarters believes that it is a contributing factor to the country’s deficit on human resource for health.

Nurses and Midwives Council of Malawi (NMCM) is the self-governing body empowered under the Laws of Malawi Chapter 36:02 and Nurses and Midwives Act No. 16 of 1995 to regulate the practice of nurses and midwives in the country.

As such, after graduation from different nursing and midwifery colleges, one takes the licensure exam in order to receive his or her nursing or midwifery license. A nursing or midwifery license gives an individual the permission to practice and is granted by the government when one met the requirements.

The national licensure examinations are developed and owned by the Nurses and Midwives Board. The Board administers these examinations to all nurses and midwives in Malawi in order to ensure public protection.

The licensure examinations are designed to test the knowledge, skills and abilities essential for the safe and effective practice of nursing and midwifery at the entry-level.

In the year 2014, students on degree level (BSCN/M) at Kamuzu Collage of Nursing (KCN) a constituent college of University of Malawi, Daeyang Collage of Nursing as well as Mzuzu University (MZUNI) wrote the licensure exams in which they were assessed midwifery and general nursing in separate categories.

Few of them 40% passed and were deployed in various hospitals whilst a larger group of students 60% passed one part of the program either general nursing or midwifery only.

According to notifications given to them by NMCM says the individuals have to be given the license and be allowed to practice as they wait to resit for the next exam in the part that they have failed.

Majority of these students were not deployed to practice their skills in the part which they did well until they re-write and pass the remaining part. An individual is required to write licensure exams for three consecutive. There are others whose period expired and as such others have changed career out of frustration. Some have join teaching in private schools whilst others are working in various private clinics.

An investigation by this reporter indicates that although 40plus students who failed the 2014 licensure exams were denied certificates to practice, there were other privileged students that had chance to practice only one category that they did well during NMCM licensure exams.

Wilton, a student from Daeyang Collage in Lilongwe is one individual who passed only general nursing but he got and a chance of being deployed at Kasungu District Hospital where he is allowed to practice only general nursing and restricted to enter the maternity ward since he did not do well during NMCM licensure exam in midwifery.

A concerned student who seeks anonymity due to the threats that may fall upon him says, “We would like to practice the skills we learned in college, we want to make a difference in our country by filling the gap which is there. There are several nurses in the hospital that did not do midwifery in college yet they only practice general nursing. Government is also training community midwives (azamba) and allowed to practice only that part, why not us.”

Chitipa District Hospital is one of the health facilities which have been hit by shortages of nurses; at one time it had only 24 nurses but the district is supposed to have 124 nurses.  Discussions are still under way between the District Commissioner and the hospital management on how best they can rectify the problem. Imagine the change that could have been there if the entire 40 plus nurses who failed licensure exams were all deployed.

Bupe Mwamba, a Zambian midwifery nurse and currently doing Master’s Degree in Maternal and Child Health at University of Cape Town in South Africa says; “I am registered nurse midwifery in my country; Zambia and never wrote any exams besides school exams. It is the same practice here in South Africa and most parts in the region.

“A licensure exam after school exams is a bad practice which Malawi should stop with immediate effect. Why should nurses undergo another exam after being in school for years,” wondered Mwamba saying “it does not make sense that one could pass University exams and fail miserably on licensure exams.”

Part IV of the Nurses and Midwives Act Cap 36:02 of the Laws of Malawi says any person who practices any category of nursing or midwives without being registered in respect of such category or while his/her right to practice such category is suspended shall be liable to a fine and imprisonment.

Thokozire Lipato, Acting Registrar and Director of Monitoring, Evaluation and Investigation at Nurses and Midwives Council of Malawi say the practice of nursing requires specialized knowledge, skill, and independent decision making. Nursing and Midwifery careers take widely divergent paths-practice focus varies by setting, by type of client, by different disease, therapeutic approach or level of rehabilitation.

Lipato said, moreover, nurses and midwives are mobile and sophisticated and work in a society that is changing and asymmetrical for consumers. The result is that the risk of harm is inherent in the provision of nursing care.

Because nursing and midwifery care poses a risk of harm to the public if practiced by professionals who are unprepared or incompetent, the state, through its policies and powers, is required to protect its citizens from harm. That protection is in the form of reasonable laws to regulate nursing and midwifery.

“Regulation is one of the ways governments serve and protect the public. There are several regulated health professions in Malawi. They are regulated by government-appointed licensing boards.

“Regulations helps to protect the public by ensuring that professional care or service received by the public is competent, ethical and meets the standards that society views as acceptable,” said Lipato.

She said currently Colleges are providing different Nursing and Midwifery Programs and NMCM put them on the Register according to the Course they been enrolled and gone through as such they cannot be given the license only on the part they have passed until they attempt the period of three attempts.

“If they fail on the three attempts, it is up to the discretion of the Board of Nursing and Midwifery to make a decision on whether they should be allowed to practice on the part they have passed. This is by critically looking at the number of students that have failed after attempting three times not on an individual basis,” says Lipato.

These licensure exams are written twice, in April and October every year and just recently a group of aspiring nurses has failed miserable the licensure exams. Recent pass rate at Ekwendeni Nursing School is 30% while Holy Trinity Nursing School got 14% pass rate.

It is believed that most students fail the licensure exams because they are in a form of multiple choices hence denying student to explain their knowledge when answering. Although there is need to hear this loud cry there is also a need to think about protecting the public anyway.

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