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Objective To assess medical and nursing students' intentions to migrate abroad or practice in rural areas. Methods We surveyed 3199 first- and final-year medical and nursing students at 16 premier government institutions in Bangladesh, Ethiopia, India, Kenya, Malawi, Nepal, the United Republic of Tanzania and Zambia. The survey contained questions to identify factors that could predict students' intentions to migrate. Primary outcomes were the likelihoods of migrating to work abroad or working in rural areas in the country of training within five years post-training. We assessed predictors of migration intentions using multivariable proportional odds models. Findings Among respondents, 28% (870/3156) expected to migrate abroad, while only 18% (575/3158) anticipated a rural career. More nursing than medical students desired professions abroad (odds ratio, OR: 1.76; 95% confidence interval, CI: 1.25- 2.48). Career desires before matriculation correlated with current intentions for international (OR: 4.49; 95% CI: 3.21-6.29) and rural (OR: 4.84; 95% CI: 3.52-6.66) careers. Time spent in rural areas before matriculation predicted the preference for a rural career (20 versus 0 years: OR: 1.53,95% CI: 1.19-1.98) and against work abroad (20 versus 0 years: OR: 0.69,95% CI: 0.50-0.96). Conclusion A significant proportion of students surveyed still intend to work abroad or in cities after training. These intentions could be identified even before matriculation. Admissions standards that account for years spent in rural areas could promote greater graduate retention in the country of training and in rural areas. [TEXT NOT REPRODUCIBLE IN ASCII] Objectif Evaluer les intentions des etudiants en medecine et en soins infirmiers concernant une emigration a l'etranger ou une pratique dans les zones rurales. Methodes Nous avons interroge 3199 etudiants en premiere annee et en derniere annee de medecine ou de soins infirmiers dans les 16 plus grandes institutions gouvernementales au Bangladesh, en Ethiopie, en Inde, au Kenya, au Malawi, au Nepal, en Tanzanie et en Zambie. Eenquete contenait des questions pour identifier les facteurs qui pourraient predire les intentions d'emigration des etudiants. Les resultats primaires etaient les probability d'emigration en vue de travailler a l'etranger ou dans les zones rurales du pays ou a ete livree la formation, dans les cinq ans suivant la fin de la formation. Nous avons evalue les indicateurs des intentions d'emigration en utilisant des modeles a cotes proportionnelles multivaries. Resultats Parmi les repondants, 28% (870/3156) esperent emigrer a l'etranger, alors que seuls 18% (575/3158) envisagent une carriere en zone rurale. Les etudiants infirmiers desirant pratiquer a l'etranger (rapport des cotes, RC: 1,76; intervalle de confiance a 95%, IC 95%: 1,25-2,48) etaient plus nombreux que les etudiants en medecine. Les souhaits de carriere avant toute installation officielle etaient correles avec les intentions actuelles pour les carrieres a l'international (RC: 4,49; IC 95%: 3,21-6,29) et dans les zones rurales (RC: 4,84; IC 95%: 3,52-6,66). Le temps passe dans les zones rurales avant installation predit une preference pour une carriere rurale (20 contre 0 annee: RC: 1,53; IC 95%: 1,19-1,98) et contre le fait de travailler a l'etranger (20 contre 0 annee: RC: 0,69; IC 95%: 0,50-0,96). Conclusion Une part importante des etudiants interroges continue a vouloir travailler a l'etranger ou dans les villes apres la fin de leur formation. Ces intentions pouvaient etre identifies meme avant leur installation. Des normes d'admission favorisant les etudiants en medecine et en soins infirmiers avec des origines rurales pourraient favoriser une meilleure retention des diplomes dans le pays de leur formation et dans les zones rurales. [TEXT NOT REPRODUCIBLE IN ASCII] Objetivo Evaluar las intenciones de los estudiantes de medicina y enfermeria de emigrar al extranjero o trabajar en zonas rurales. Metodos Se encuesto a 3199 estudiantes de medicina y enfermeria de primer y ultimo curso de 16 instituciones gubernamentales de primer nivel en Bangladesh, Etiopla, India, Kenya, Malawi, Nepal, Tanzania y Zambia. La encuesta incluyo preguntas para identificar los factores que podrian predecir las intenciones de emigrar de los estudiantes. Los resultados primarios fueron las probabilidades de emigrar para trabajar en el extranjero o en zonas rurales en el pais de formation en los cinco arios posteriores a esta. Los indicadores de las intenciones de migration se evaluaron por medio de modelos de probabilidades proporcionales multivariables. Resultados Entre los encuestados, el 28 % (870/3156) esperaba emigrar al extranjero, mientras que solo el 18 % (575/3158) preveia una carrera rural. Mas estudiantes de enfermeria que de medicina deseaban desarrollar su profesion en extranjero (proportion de probabilidad, OR: 1,76; intervalo de confianza del 95 %, IC: 1,25-2,48). Los deseos sobre la carrera profesional antes de la matriculation se correspondlan con los deseos actuates de desarrollar una carrera international (OR: 4,49; 95 % IC: 3,21-6,29) y rural (OR: 4,84; 95 % IC: 3,52-6,66). El tiempo pasado en zonas rurales antes de la matriculation predijo la preferencia por una carrera rural (20 frente a 0 arios: OR: 1,53; 95 % IC: 1,19-1,98) yen contra de trabajar en el extranjero (20 frente a 0 arios: OR: 0,69; 95 % IC: 0,50-0,96). Conclusion Una proportion significativa de los estudiantes encuestados todavla tiene la intention de trabajar en el extranjero o en ciudades una vez finalizados los estudios. Dichas intenciones pudieron identificarse inclusoantes de la matriculation. Las normas de admision quefavorecen a los estudiantes de medicina y enfermeria de zonas rurales podrian promover una mayor retention de los graduados en el pais deformation yen las zonas rurales., Introduction Shortages of physicians and nurses jeopardize health system advances in many low- and middle-income countries (LMIC). (1,2) Sub-Saharan Africa has only 2 doctors and 11 nurses or midwives per [...]

Abstract Background In 2004, the Malawian Ministry of Health declared a human resource crisis and launched a six year Emergency Human Resources Programme. This included salary supplements for key health workers and a tripling of doctors in training. By 2010, the number of medical graduates had doubled and significantly more doctors were working in rural district hospitals. Yet there has been little research into the views of this next generation of doctors in Malawi, who are crucial to the continuing success of the programme. The aim of this study was to explore the factors influencing the career plans of medical students and recent graduates with regard to four policy-relevant aspects: emigration outside Malawi; working at district level; private sector employment and postgraduate specialisation. Methods Twelve semi-structured interviews were conducted with fourth year medical students and first year graduates, recruited through purposive and snowball sampling. Key informant interviews were also carried out with medical school faculty. Recordings were transcribed and analysed using a framework approach. Results Opportunities for postgraduate training emerged as the most important factor in participants’ career choices, with specialisation seen as vital to career progression. All participants intended to work in Malawi in the long term, after a period of time outside the country. For nearly all participants, this was in the pursuit of postgraduate study rather than higher salaries. In general, medical students and young doctors were enthusiastic about working at district level, although this is curtailed by their desire for specialist training and frustration with resource shortages. There is currently little intention to move into the private sector. Conclusions Future resourcing of postgraduate training opportunities is crucial to preventing emigration as graduate numbers increase. The lesser importance put on salary by younger doctors may be an indicator of the success of salary supplements. In order to retain doctors at district levels for longer, consideration should be given to the introduction of general practice/family medicine as a specialty. Returning specialists should be encouraged to engage with younger colleagues as role models and mentors.

Abstract Background Malawi has one of the lowest physician densities in the world, at 1.1 doctors per 100,000 population. Undergraduate training of doctors at the national medical school has increased considerably in recent years with donor support. However, qualified doctors continue to leave the public sector in order to work or train abroad. We explored the postgraduate plans of current medical students, and the extent to which this is influenced by their background. Methods A self-administered questionnaire was developed after discussion with students and senior staff. This included questions on background characteristics, education before medical school, and future career plans. This was distributed to all medical and premedical students on campus over 1 week and collected by an independent researcher. One reminder visit was made to each class. Chi-squared tests were performed to investigate the relationship of student characteristics with future career plans. Results One hundred and forty-nine students completed the questionnaire out of a student body of 312, a response rate of 48%. When questioned on their plans for after graduation, 49.0% of students plan to stay in Malawi. However, 38.9% plan to leave Malawi immediately. Medical students who completed a ‘premedical’ foundation year at the medical school were significantly more likely to have immediate plans to stay in Malawi compared to those who completed A-levels, an advanced school-leaving qualification (P = 0.037). Current premedical students were slightly more likely to have immediate plans to work or train in Malawi compared to medical students (P = 0.049). However, a trend test across all the years was not significant. When asked about future plans, nearly half of students intend to work or train outside Malawi. Conclusions The majority of respondents plan to leave Malawi in the future. The effectiveness of the substantial upscaling of medical education in Malawi may be diminished unless more medical students plan to work in Malawi after graduation.

Background: Eighty per cent of Malawi's 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health. Presentation of the hypothesis: Managed clinical networks have been found to improve equity of care in rural districts and to ensure that the correct care is provided as close to home as possible. A network for paediatric care in Malawi with mentoring of non-physician clinicians based in a district hospital by paediatricians based at the central hospitals will establish and sustain clinical referral pathways in both directions. Ultimately, the plan envisages four managed paediatric clinical networks, each radiating from one of Malawi's four central hospitals and covering the entire country. This model of task sharing within four hub-and-spoke networks may facilitate wider dissemination of scarce expertise and improve child healthcare in Malawi close to the child's home. Testing the hypothesis: Funding has been secured to train sufficient personnel to staff all central and district hospitals in Malawi with teams of paediatric specialists in the central hospitals and specialist non-physician clinicians in each government district hospital. The hypothesis will be tested using a natural experiment model. Data routinely collected by the Ministry of Health will be corroborated at the district. This will include case fatality rates for common childhood illness, perinatal mortality and process indicators. Data from different districts will be compared at baseline and annually until 2020 as the specialists of both cadres take up posts. Implications of the hypothesis: If a managed clinical network improves child healthcare in Malawi, it may be a potential model for the other countries in sub-Saharan Africa with similar cadres in their healthcare system and face similar challenges in terms of scarcity of specialists. [ABSTRACT FROM AUTHOR]

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