title: What makes staff consider leaving the health service in Malawi?
abstract: BACKGROUND
  Malawi faces a severe shortage of health workers, a factor that has contributed greatly to high maternal mortality in the country. Most clinical care is performed by mid-level providers (MLPs). While utilization of these cadres in providing health care is a solution to the current shortages, demotivating factors within the Malawian health system are pushing them into private, non-governmental, and other non-health related positions. This study aims to highlight these demotivating factors by exploring the critical aspects that influence MLPs' intention to leave their jobs.
  
  
  METHODS
  This descriptive qualitative study formed part of the larger Health Systems Strengthening for Equity (HSSE) study. Data presented in this paper were collected in Malawi using the Critical Incident Analysis tool. Participants were asked to narrate an incident that had happened during the past three months which had made them seriously consider leaving their job. Data were subjected to thematic analysis using NVivo 8 software.
  
  
  RESULTS
  Of the 84 respondents who participated in a Critical Incident Analysis interview, 58 respondents (69%) indicated they had experienced a demotivating incident in the previous three months that had made them seriously consider leaving their job. The most commonly cited critical factors were being treated unfairly or with disrespect, lack of recognition of their efforts, delays and inconsistencies in salary payments, lack of transparent processes and criteria for upgrading or promotion, and death of patients.
  
  
  CONCLUSIONS
  Staff motivation and an enabling environment are crucial factors for retaining MLPs in the Malawian health system. This study revealed key 'tipping points' that drive staff to seriously consider leaving their jobs. Many of the factors underlying these critical incidents can be addressed by improved management practices and the introduction of fair and transparent policies. Managers need to be trained and equipped with effective managerial skills and staff should have access to equal opportunities for upgrading and promotion. There is need for continuous effort to mobilize the resources needed to fill gaps in basic equipment, supplies, and medicine, as these are critical in creating an enabling environment for MLPs.
authors.affiliation: University of Malawi, College of Medicine, Centre for Reproductive Health, Blantyre, Malawi. wchimwaza@medcol.mw.
authors.forename: Wanangwa
authors.initials: W
authors.lastname: Chimwaza
authors.forename: Effie
authors.initials: E
authors.lastname: Chipeta
authors.forename: Andrew
authors.initials: A
authors.lastname: Ngwira
authors.forename: Francis
authors.initials: F
authors.lastname: Kamwendo
authors.forename: Frank
authors.initials: F
authors.lastname: Taulo
authors.forename: Susan
authors.initials: S
authors.lastname: Bradley
authors.forename: Eilish
authors.initials: E
authors.lastname: McAuliffe
mesh_terms: D001291:Attitude of Health Personnel; D002055:Burnout, Professional; D006282:Health Personnel; D006801:Humans; D033182:Intention; D007407:Interviews as Topic; D007588:Job Satisfaction; D008295:Malawi; D009042:Motivation; D010563:Personnel Turnover; D036301:Qualitative Research; D012456:Salaries and Fringe Benefits