This paper examines the employment preferences of public sector registered nurses working in Malawi and identifies the range and relative importance of the factors

that affect their motivation. The research was designed in the light of the Malawi government’s programme to address the shortage of health workers, which is based on salary top-ups as a means of increasing employee motivation and reducing high rates of attrition. This policy has been adopted despite relatively little quantitative exploration into the employment preferences of health workers in developing countries. This study aims to provide a clearer picture of the preferences of registered nurses about different aspects of their employment, and the factors that might persuade them to continue in the profession within their home country.

In many developing countries, efforts to improve health outcomes are constrained

by the critical shortages of health workers. The provision of health care is labour-intensive, and health workers play a central role in the diagnosis, treatment and care of patients. Although there is a global shortage of health workers, the most critical

shortfalls occur in sub-Saharan Africa. This reflects a legacy of underinvestment in human resources, the devastating impact of communicable diseases including HIV/AIDS on health workers, and the migration of health personnel seeking alternative employment overseas. The extent of the health worker shortage is widely recognised and there is an emerging body of literature on human resources for health (Joint Learning Initiative, 2004; World Health Organization, 2006), which provides a good overview of the global situation and identifies a range of generic reasons for the shortage of health workers, including poor remuneration and difficult working conditions.

The shortage of health workers in Malawi is severe even by African standards, with

fewer than 4000 doctors, nurses and midwives serving a population of approximately 12 million in 2003 (Joint Learning Initiative, 2004). The coverage and quality of health services are adversely affected by the low density of professional health workers. With support from international donors, in 2004 the Malawi government designed a comprehensive programme to alleviate the human resource crisis in the health sector. The implementation of the six-year programme, known as the Emergency Human Resources Programme, began in April 2005 and contained three key components: a salary increase for health professionals; measures to enhance the capacity of training institutions; and, in the short term, additional recruitment of expatriate volunteer doctors and nursing tutors (Palmer, 2006). Of the three components, the salary top-up scheme is designed to improve the working

conditions for existing staff, and aims to increase retention of health workers in the

public service. In addition, some factors affecting the motivation and retention of health workers, such as the availability of drugs and other supplies, are undergoing reform as part of the Malawi government’s sector-wide programme to improve the health of the population and the provision of health care.

This paper presents the results of a discrete choice experiment designed to elicit the employment preferences of public sector registered nurses in Malawi. For practical

and financial reasons, it was necessary to limit the research to a single cadre: registered nurses were chosen as this cadre faces acute shortages and particular

difficulties in retaining staff.