Observation (CEACR) - adopted 2020, published 109th ILC session (2021)

Nursing Personnel Convention, 1977 (No. 149) - Malawi (Ratification: 1986)

Article 2 of the Convention. National policy concerning nursing services and nursing personnel. Consultation. The Committee notes with interest the range of policy initiatives adopted by the Government during the reporting period in relation to public health services and the health workforce, particularly with respect to nursing services and nursing personnel. These policies were developed following consultation with and through the active participation of the relevant stakeholders, including the private sector, health training institutions, relevant regulatory bodies and civil society organizations. The Committee notes the adoption of Malawi’s first National Health Policy (NHP) in July 2017, which establishes an overarching framework to guide the achievement of the country’s health sector. It includes among its priority areas: health service delivery; human resources for health; leadership and governance; and health financing. In relation to the health workforce, the 2017 NHP contemplates the adoption of measures to ensure that a sufficient number of adequately trained and motivated health workers, including nurses, are recruited, deployed and retained in line with the health needs of the population at all levels of healthcare service delivery. The Committee also notes the adoption of the medium-term Health Sector Strategic Plan II (HSSP II) in 2017, which outlines a range of objectives and activities and guides for the use of resources during 2017–22. The HSSP II a set of priority strategies, including: improving retention and recruitment of properly deployed and motivated health workers and strengthening the health workforce planning process. The Committee further notes the development, in alignment with the above-mentioned policies on health and health workers, of the Nursing and Midwifery Policy (NMP), adopted in June 2018. The 2018 NMP provides a framework for the provision of comprehensive, quality and equitable nursing and midwifery services that will contribute to achieving the country’s health-related goals. However, challenges noted in the 2018 NMP include a high disease burden in the country, as well as high rates of maternal mortality (439 per 100,000 births), neonatal mortality (27 per 1,000 live births) and an under-5 mortality rate of 64 per 1,000. It is noted that the maternal mortality ratio will need to be reduced by 84 per cent to meet Sustainable Development Goal targets. The main objectives of the 2018 NMP include: reducing nursing and midwifery vacancy rates from the current 63 per cent to 50 per cent by 2022; providing guidance to decision-makers, stakeholders and partners for the effective planning and implementation of nursing and midwifery services; facilitating delivery of quality nursing and midwifery services; supporting quality clinical mentorship and supervision of nursing students; and timely placement of new nursing and midwifery graduates. In addition, the 2018 NMP envisages the participation of a broad range of actors in its monitoring and implementation, including workers’ organizations, nurses’ associations, private sector organizations, development partners, and non-governmental organizations. In addition, the Committee notes the implementation of the Malawi German Health Programme (MGHP), which calls for the adoption of measures, in line with the 2017 NHP and the HSPP II, to ensure a better distribution and increased qualification of clinical and nursing staff in the area of maternal and newborn healthcare. The Committee requests the Government to provide detailed, up-to-date information on the measures taken in the context of the National Health Policy, the Health Sector Strategic Plan II 2017–22, the Nursing and Midwifery Policy and the Malawi German Health Programme, as well as on their impact in practice. In particular, the Committee requests the Government to provide detailed information on the implementation and impact of those measures designed to provide nursing personnel with employment and working conditions, including career prospects and remuneration, which are likely to attract persons to the profession and retain them in it.

Community health nursing. The Committee notes that, according to the HSSP II, a significant proportion of Malawi’s population (84 per cent) has no access to healthcare, especially those persons residing in rural and hard-to-reach areas of the country. In this context, the Committee notes the adoption of the country’s first National Community Health Strategy 2017–22 (NCHS) in November 2017, which is aligned with existing national health policies as well as with the HSSP II. The 2017 NCHS was developed following an intensive consultative process with relevant stakeholders in the health sector, which included local communities. The principal objective of the 2017 NCHS is to ensure quality, integrated community health services that are affordable, culturally acceptable, scientifically appropriate, and accessible to every household. In order to achieve this goal, the 2017 NCHS includes among its strategic objectives that of building a sufficient, equitably distributed, well-trained community health workforce that includes community nursing personnel. The Committee notes that, according to the 2017 NCHS, there is a shortage of community nurses. Moreover, the 2017 NCHS indicates that community nurses are being used to fill gaps at health facilities and are therefore spending less time on community work. They face challenges that include: lack of clarity regarding their roles and tasks; inadequate training and supervision; and poor incentives. To address the shortage of adequately trained and motivated community health workers (CHWs), the 2017 NCHS sets out a number of key interventions: recruitment of additional CHWs, including a minimum of two community health nurses (CHNs) per health centre and one community midwife assistant (CMA) per community health delivery structure; promoting equitable geographical distribution of CHWs; and providing high-quality, integrated pre-service and in-service training to all CHWs. The 2017 NCHS also envisages the launch of a more standardized package of financial, non-financial, social and performance-based incentives aimed at increasing the retention of CHWs and supporting their strong performance across the country. The Committee further notes that the 2018 NMP includes a policy priority area on community health nursing and midwifery. In this regard, the 2018 NMP includes the following strategies, among others: providing leadership for community health nursing and midwifery services and strengthening such services by integrating community health nursing interventions in all nursing and midwifery services. The Committee requests the Government to provide detailed updated information on the effective implementation, monitoring and impact of the measures adopted in the framework of the National Community Health Strategy 2017–22 and the 2018 Nursing and Midwifery Policy with regard to nursing services and nursing personnel, including nurses, midwives and community health workers.

Mental health nurses. The Committee notes that, according to the HSSP II, there are many people in Malawi with mental disorders, a majority of whom seek medical care at health facilities, but are misdiagnosed due to presenting with physical symptoms. Common disorders such as depression and anxiety, whose prevalence is estimated at 10–20 per cent are often missed or not treated. The Government indicates in the HSSP II that, although at least 20 psychiatric nurses and psychiatric clinical officers are trained every year, the number of psychiatric staff actively carrying out mental health-related activities is very low due to the general shortage of nurses in the health system. The Committee requests the Government to provide updated detailed information on the measures taken or envisaged to ensure the quantity and quality of mental health nursing care necessary for attaining the highest possible level of health for the population.

Article 2(2)(a) and (3). Nursing education and training. The Committee notes that the HSSP II places a priority on improving the quality of training through the expansion of training and education opportunities, including through continuing professional development (CPD). The HSSP II provides for the adoption of specific measures to promote quality nursing and midwifery pre-service education, such as measures to institutionalize periodic curriculum reviews for all training institutions, as well as institutionalizing student–tutor ratios for specified nursing and midwifery training programmes; and measures to promote continued collaboration between teaching and clinical/community staff. The HSSP II also calls for the implementation of measures that encourage all nurses and midwives to pursue CPD, by institutionalizing CPD and supporting nurses and midwives undergoing upgrading courses and in-service training. The Committee notes in this regard that mandatory CPD for nurse midwives was re-introduced by the Nurses and Midwives Council of Malawi with the assistance of the MGHP. The Committee requests the Government to provide updated detailed information on the nature, implementation, monitoring and impact of the measures adopted, to ensure that nursing personnel, including midwives, are provided with quality education and training appropriate to the exercise of their functions as well as to their professional career development.

Article 5(2). Determination of conditions of employment and work. In response to the Committee’s previous comments, the Government indicates that the collective bargaining agreement for the nursing sector has still not been concluded. The Committee requests the Government to continue to provide information on the status of the collective bargaining process and progress made in this regard, as well as to transmit a copy of any collective agreements concluded for the nursing sector.

Article 7. Occupational safety and health. The Committee notes that the President of Malawi declared a state of national disaster in response to the COVID-19 pandemic on 19 March 2020. The National Covid-19 Preparedness and Response Plan was subsequently launched for the period March–June 2020. The Plan includes among its specific objectives building the capacity of healthcare workers on highly infectious diseases (such as COVID-19), as well as procuring and distributing supplies and equipment to all treatment centres. In this regard, the Committee draws the attention of the Government to paragraph 49 of the Nursing Personnel Recommendation, 1977 (No. 157), which provides that: “(1) all possible steps should be taken to ensure that nursing personnel are not exposed to special risks. Where exposure to special risks is unavoidable, measures should be taken to minimise it; (2) measures such as the provision and use of protective clothing, immunisation, shorter hours, more frequent rest breaks, temporary removal from the risk or longer annual holidays should be provided for in respect to nursing personnel regularly assigned to duties involving special risks so as to reduce their exposure to these risks; and (3) in addition, nursing personnel who are exposed to special risks should receive financial compensation.” The Committee also draws the Government’s attention to the ILO Guidelines on decent work in public emergency services, 2018, which recognize the need to protect public emergency workers, including emergency health workers, from exposure to communicable diseases. In particular, paragraphs 50 and 51 of the Guidelines stress that suitable and sufficient personal protective equipment (PPE) should be provided as protection against exposure to hazardous conditions for public emergency services’ workers and that workers and/or their representatives should be consulted and participate in relation to the selection and correct use of PPE. Noting that nursing personnel, as they are often in close contact with patients, are at high risk of being infected while treating patients with suspected or confirmed COVID-19 when infection control precautions, including use of personal protective equipment (PPE) are not strictly practiced, the Committee requests the Government to provide detailed updated information on the safety measures being taken or that are envisaged, including the provision of PPE and training in its use, as well as provision of adequate rest breaks during workers’ shifts and limitations on excessive hours wherever possible, with a view to protecting the health and well-being of nurses and limiting as much as possible their risk of contracting COVID-19.

Part V of the report form. Application in practice. The Committee notes that, according to the WHO Global Health Observatory, the total number of nursing and midwifery personnel in Malawi increased from 4,573 in 2016 to 7,957 in 2018. Nevertheless, the HSSP II indicates that the overall vacancy rate for nursing officers is currently 66 per cent (63 per cent among assistant community health officers, 72 per cent for chief nurse technicians, 45 per cent for chief nursing officers and 31 per cent for community midwifery assistants). This personnel shortage places a heavy burden on those nursing and midwifery professionals who are in employment. The Committee requests the Government to provide updated detailed information on the application of the Convention in practice, including statistical data disaggregated by sex, age and region concerning: the ratio of nursing personnel to the population; the number of persons enrolled in nursing schools; the number of female and male nurses who enter and leave the profession each year; the organization and the operation of all institutions which provide healthcare services; as well as official studies, surveys and reports addressing health workforce issues in the Malawi health sector.