title: Early career retention of Malawian medical graduates: a retrospective cohort study.
abstract: OBJECTIVE
  There have been longstanding concerns over Malawian doctors migrating to high-income countries. Early career is a particularly vulnerable period. After significant policy changes, we examined the retention of recent medical graduates within Malawi and the public sector.
  
  
  METHODS
  We obtained data on graduates between 2006 and 2012 from the University of Malawi College of Medicine and Malawi Ministry of Health. We utilised the alumni network to triangulate official data and contacted graduates directly for missing or uncertain data. Odds ratios and chi-squared tests were employed to investigate relationships by graduation year and gender.
  
  
  RESULTS
  We traced 256 graduates, with complete information for more than 90%. Nearly 80% of registered doctors were in Malawi (141/178, 79.2%), although the odds of emigration doubled with each year after graduation (odds ratio = 1.98, 95% CI = 1.54-2.56, P < 0.0001). Of the 37 graduates outside Malawi (14.5%), 23 (62.2%) were training in South Africa under a College of Medicine sandwich programme. More than 80% of graduates were working in the public sector (185/218, 82.6%), with the odds declining by 27% for each year after graduation (odds ratio = 0.73, 95% CI = 0.61-0.86, P < 0.0001).
  
  
  CONCLUSIONS
  While most doctors remain in Malawi and the public sector during their early careers, the odds of leaving both increase with time. The majority of graduates outside Malawi are training in South Africa under visa restrictions, reflecting the positive impact of postgraduate training in Malawi. Concerns over attrition from the public sector are valid and require further exploratory work.
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Kate L
authors.initials: KL
authors.lastname: Mandeville
authors.forename: Godwin
authors.initials: G
authors.lastname: Ulaya
authors.forename: Mylene
authors.initials: M
authors.lastname: Lagarde
authors.forename: Lyson
authors.initials: L
authors.lastname: Gwesele
authors.forename: Titha
authors.initials: T
authors.lastname: Dzowela
authors.forename: Kara
authors.initials: K
authors.lastname: Hanson
authors.forename: Adamson S
authors.initials: AS
authors.lastname: Muula
mesh_terms: D002321:Career Choice; D002322:Career Mobility; D004501:Education, Medical / Q000706:statistics & numerical data*; D004641:Emigration and Immigration / Q000706:statistics & numerical data*; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D010563:Personnel Turnover / Q000706:statistics & numerical data*; D017150:Public Sector; D012189:Retrospective Studies; D000078329:Workforce
keywords: Malawi; doctores; doctors; educación médica; health policy; human resources for health; medical education; médecins; politique de santé; política sanitaria; recursos humanos en salud; ressources humaines pour la santé; retención; retention; rétention; éducation médicale