In Malawi, where the healthcare system frequently makes headlines for its shortages of drugs and medical workers, a fact that is often overlooked is that two out of four central hospitals do not have a specialist physician in attendance.

“A lot of conditions are not appropriately diagnosed because they are seen by clinicians who are not aware of the greater spectrum of diagnoses that are possible,” explains Dr. Theresa Allain, associate professor and head of Internal Medicine at the University of Malawi’s College of Medicine in Blantyre. “When things are not diagnosed appropriately, they’re not treated appropriately.”

“So there is a need for higher-level specialism, but we don’t have enough doctors yet to go into those posts,” she tells the media.

And while much of the blame for the slow development of Malawi’s healthcare system has fallen on the external “brain drain”, whereby qualified medical workers leave Malawi in favour of better training opportunities and more attractive salaries abroad, Allain explains that the challenges go far beyond this single factor.

“We have to look at it in the context of the bigger picture because the College of Medicine is only 20 years old,” she says of the country’s fledgling medical training institute. “The first phase of the life of a medical school is just getting doctors qualified.”

In a 2010 report, the World Health Organization found Malawi had just 257 doctors serving a population of over 15 million.

There are currently 459 general medical practitioners registered with the Medical Council of Malawi.

Despite the increasing number, however, there are only 177 specialists in the country and the doctor-to-patient ratio remains alarmingly high at 1:33,300.

In Kenya, there are 1,654 registered specialists and the doctor-to-patient ratio is markedly lower at 1:5,190. And south of Malawi, South Africa has over 9,600 registered specialists and boasts a doctor-to-patient ratio of 1:1,320.
“It’s an evolving health service,” says Allain. “But each year, we graduate more doctors, and what’s interesting now is that the new graduates are beginning to demand better postgraduate opportunities.”

Andrew Mataya, 28, is a fifth year student of the Bachelor of Medicine programme at the College of Medicine and the possibility of specialising is one that he is now reflecting on.

“I definitely would like to specialise, but I’m not quite sure which area to pursue yet,” he tells IPS, explaining that when it comes to making this decision, he will take into consideration the working nature of that specialty, his relationships with his instructors and supervisors, and the service needs of Malawi.

“My career path, of course, depends on which specialty I ultimately do choose, and what opportunities are available when the time comes.”

In her State of the Nation address at the beginning of the year, President Joyce Banda expressed the government’s commitment to creating “a Malawi that has a healthy population, and a well-trained and skilled workforce.”

But as many of Malawi’s donor countries are confronted by a global recession, funding in multiple government sectors – not just healthcare – has decreased, indirectly affecting medical training programmes.

“The Ministry of Health did fund a number of specialist training posts a few years ago,” Allain explains. “But it is strapped for cash and our health service is struggling with very basic things, like drugs, so actually putting a budget aside for training specialists is not high on their priority list just at the moment.”

But that is not to say that advances have not been made.

The College of Medicine recently integrated two new programmes for higher medical specialisations: one in nephrology (renal medicine) and the other in emergency medicine.

Students would still be required to complete part of their training abroad in countries such as South Africa or Tanzania where the healthcare system is more developed. But as Allain says, the long-term goal is to create more postgraduate opportunities for those who are looking to stay and work in Malawi.

Dr. Francis Kamwendo, Deputy Head of the Obstetrics and Gynecology (OB/GYN) Department and a consultant OB/GYN at the Queen Elizabeth Central Hospital in Blantyre, has noticed a marked difference in his area of specialisation over the last decade.

“The developments are slow,” Kamwendo, who completed both his basic and specialist medical training in Sweden, tells IPS. “But we feel that we are growing, we are developing, and we are getting better at delivering special care.”

And Kamwendo envisions even more comprehensive OB/GYN services in the future.

“The department will develop in a way that will have sub-specialties,” he projects. “We will have gynecological oncology, maternal and fetal medicine, and we will also be able to take care of other diseases that a woman may have before she becomes pregnant, such as diabetes and hypertensive disease.”

Although Malawi is now looking to train more specialist physicians and its educational institutes are maturing to accommodate this development, Allain reiterates the need to first generate general specialists who are equipped with a high-level knowledge base that will enable them to treat the country’s most common medical conditions up to specialist level.

These conditions include pneumonia, tuberculosis, HIV, stroke, heart failure, and anemia.

“If you’ve only got 300 doctors, and perhaps you’re going to train 20 specialists, you don’t want to train very specialised doctors,” she says.

“If we train specialist cardiologists, they’d be able to look after one of those conditions, which is heart failure.”
In the meantime, Malawi has turned to “task shifting” in order to temporarily combat the lack of human resources available to its healthcare system, whereby less specialised health workers – known as clinical officers – are designated low-risk tasks, such as giving injections, performing HIV tests, and applying local anaesthetics.

And as for building up Malawi’s medical specialist sector, it is a process that will simply take time, says Kamwendo.

“Now that we are planning specialist education, it will help us produce specialists that will remain in the central hospitals, and they will overflow to the district hospitals with time.”