In her childhood days, 24 year-old Idah Jere, harboured ambitions to become a nurse, drawing inspiration from a certain nurse at Embangweni Hospital, a few kilometres from Ephangweni Mission Primary School where she was schooling.
“She treated patients with care and love. I looked up to her as my best role model,” she explains.
That was 18 years ago when the nurse-to-patient ratio was, according to National Organisation of Nurses and Midwives (Nonm) president Dorothy Ngoma, about one nurse to 20 or 30 patients and service delivery in public hospitals was of high quality.
“I don’t admire nursing any more. The profession has many challenges. How can one nurse be assigned to over 80 patients per shift?” she wonders.
Ngoma says the number of practising nurses stands at 10 000 against a projected population of 16 million.
This means each nurse treats an average of about 1 600 patients against a recommended nurse-to-patient ratio of one to six.
Malawi Health Equity Network (Mhen) executive director Martha Kwataine warns that Malawi is sitting on a ticking time-bomb by not training more healthcare workers and subsequently recruiting them to match the ever-increasing population.
Kwataine notes the high nurse-to-patient ratio provides a fertile ground for compromised service leading to death of patients, especially the poor who rely on free medical care.
The International Council of Nurses (ICN) recommends one nurse for six ‘average sick’ patients or one-to-one in the seriously sick patients to ensure safe and quality patient care.
ICN, a federation of more than 130 national nurses’ associations representing millions of nurses worldwide, stresses that the diminishing number of nurses against the increasing workloads put both patients and healthcare workers at risk of infection and unprofessional conduct due to fatigue and other disappointments.
Ngoma notes that Malawi has one of the highest nurse-to-patient ratio in Africa and the world over, currently hovering around one to 80.
She cites Kamuzu Central Hospital (KCH) where a paediatric ward with 400 patients is assigned five nurses, thus committing an average of 80 patients to one nurse.
The situation is similar at Queen Elizabeth Central Hospital (QECH) where a single nurse looks after 80 or more patients per shift, according to chief hospital administrator Themba Mhango.
However, the situation is slightly different at Zomba Central Hospital where chief hospital administrator Thom Chisale says, at worst, a nurse is assigned to look after 40 paediatric patients per shift.
Mzuzu Central Hospital chief hospital administrator Rose Nyirenda refused to provide the statistics.
Ngoma said she could not be surprised to see a nurse to caring for and treating over 10 ‘very sick’ patients against the recommended ratio of one to one.
She stresses: “Malawi is far from meeting the internationally recommended ratios. This is generally due to government laxity on the training and recruitment of healthcare workers.”
She, however, notes there has been an increase in the number of nurses from 4 500 in 2010 to the present 10 000 effectively reducing the vacancy rate from 76 percent to 60.
Ngoma says Malawi needs at least 50 000 practising healthcare workers to achieve best quality service for patients.
Kwataine notes that when nurses are forced to work with high nurse-to-patient ratios, patients get infections, injuries or can be discharged without knowledge on how to take care of their illness or injury back home and even die.
“On the other hand, when nurses have fewer patients, they can take better care of them thereby preventing errors and avoidable deaths. Patients are also more likely to understand how to manage their illnesses and prevent further illnesses or deterioration.
“Unfortunately, that cannot be achieved in our scenario where a nurse is assigned a legion of patients per shift,” she explains.
Kamuzu College of Nursing principal, Professor Address Malata, challenged that quality healthcare could not be achieved with the prevailing shortage of human resources in the health sector.
Malata, speaking at the Consortium for Advanced Research Training in Africa (Carta) in Lilongwe in September 2014, called for a stronger and determined collaboration between government and its stakeholders in rectifying the situation by training and recruiting adequate human resource.
According to National Association for Nurses and Midwives in Malawi (Nanm) executive director Harriet Kapyepye, the ideal number of patients a nurse can see is 10 in a general ward, one to seven for the labour ward and one to one in the intensive care unit.
However, Kapyepye notes that due to understaffing levels, one nurse cares for more than 100 patients in public health institutions.
“And when a comparison is made with other countries in the Southern African Development Community (SADC), Malawi has the lowest number of nurses in the public sector, making the nurse-patient ratio the highest,” she explained.
She said the problem is compounded by nurses’ migration to developed countries and low annual graduation of about 100 registered nurses and 400 nurse-midwife technicians against the prevailing population.
A nurse who spoke in confidence at QECH said a high nurse-patient ratio puts lives of both healthcare workers and patients at risk.
She stated that there are circumstances where a nurse would overlook infection prevention procedures (such as changing gloves) to save the life of the next patient.
Ministry of Health acting spokesperson Adrian Chikumbe says rapid population growth remains one of the major challenges affecting delivery of healthcare services in public hospitals.
“It’s not hard to match the number of patients with that of nurses as the population keeps rising each passing day,” says Chikumbe.
President Peter Mutharika, too, acknowledged in his State of the Nation Address, the existence of enormous challenges besetting delivery of healthcare services, including critical shortage of staff, non-availability of essential drugs, medical supplies and facilities.
“My administration will ensure that all districts have adequate facilities, including primary healthcare within a reasonable working distance from people’s homes; end critical shortage of staff, medicine and drugs in all hospitals and clinics across the country,” Mutharika said.
But he failed short of spelling out policies that would facilitate the realisation of this dream.
Health rights activist MazikoMatemba argues it would be a tall order for Malawians to expect that things would improve without clear policy direction.
“That would be like pleading with a bull for milk. You can’t get it no matter how you plead,” challenges Matemba.