Verah Nkosi didn’t dream of becoming a health worker. “It wasn’t always my passion,” admits the 21-year-old student of nursing-midwifery in Malawi. But she was assigned to the Kamuzu College of Nursing, and her education is supported by the government.

The skills she is acquiring are in high demand, especially in rural and remote areas. The vacancy rate for nursing and midwifery positions in Malawi’s public sector is 65%, according to the US President’s Emergency Plan for AIDS Relief (PEPFAR), and while 85% of the population lives in rural areas, only 29% of Malawi’s nursing professionals provide services there—the rest work in urban areas, according to Ministry of Health data.

Malawi has been working hard to train more students that can go on to fill these gaps. It’s no easy task, though.

In Nkosi’s class, for example, not all of the 106 students will graduate. “Some of the factors that result in the dropout of the students are pregnancy, sickness, and poor academic performance,” she explains. “The school has a regulation that requires the pregnant student to withdraw.” And those who do graduate are not likely to work in remote areas where the need is highest. Nkosi, like many health workers around the world, prefers employment in or near the capital city in a well-resourced facility. She hopes for a post “where there is not too much improvising, where I am able to adjust […]. I would look at availability of resources in the hospital such as electricity, drugs, equipment, and supplies.”

Barriers to progress

Her situation points to some of the challenges in current systems for health worker education and training. Nkosi was assigned to the College of Nursing rather than selecting it herself, many of her classmates are having trouble staying in school, and she and many of her fellow graduates will limit their job search to facilities near the capital with electricity and other resources.

Other challenges facing Malawi’s nursing and midwifery education system include a shortage of tutors and preceptors at clinical sites, insufficient teaching equipment, and lack of classroom space, according to the country’s human resources for health profile.

Partnering to improve the system

To move toward a more effective system of health worker training, Malawi is participating in the Nursing Education Partnership Initiative (NEPI), along with the Democratic Republic of the Congo (DRC), Ethiopia, Lesotho, and Zambia. NEPI is the US Government’s unified program, led by PEPFAR, to address the underproduction of nursing professionals in developing countries.

As a NEPI partner, CapacityPlus is surveying nursing schools in a number of countries in sub-Saharan Africa, including the DRC, to assess the education capacity and identify bottlenecks and gaps to increasing the number of qualified and competent graduates who will work where needed in both urban and rural settings, and at all levels of health services. In addition, the IntraHealth-led CapacityPlus project is conducting costing studies to estimate the current unit cost of producing a nurse or midwife graduate, and to estimate the incremental additional costs of increasing the quantity and quality of the graduates.

“I started loving being a nurse”

Fortunately for Verah Nkosi, as she began her training “the passion started growing in me—I started loving being a nurse.” Now in her final year of school, Nkosi sounds like a young woman who has found her path in life. “It brings satisfaction in my heart that I am serving people and my country,” she says. In the next few years she plans to get a master’s degree in neonatology and child health and looks forward to being “a recognized member of the society working for the public sector.” For now, she says, “I have the internal feeling of happiness that I am doing something to help others.”

A version of this piece was originally published as CapacityPlus Voices #10, on the CapacityPlus website.