Dan Banik and Address Malata discuss power imbalances in the global health domain, the importance of investing in the healthcare workforce and primary health infrastructure, and the major challenges facing the health sector in Malawi today.
Global health organizations are mainly located in the global North and experts from low- and middle-income countries are underrepresented in global health leadership positions. Thus, it is unsurprising that there has been considerable criticism and heated debate on who should represent the underrepresented. According to our guest this week, it is crucial to ask: Who Speaks for Whom and About What?
Professor Address Malata is the Vice Chancellor of the Malawi University of Science and Technology (MUST). She trained to be a nurse and is former President of Africa Honor Society of Nursing and former Vice President of International Confederation of Midwives. She has previously served as principal of the University of Malawi’s Kamuzu College of Nursing and is the recipient of numerous honors both at home and abroad.
Host:
Professor Dan Banik, University of Oslo, Twitter: @danbanik @GlobalDevPod
https://in-pursuit-of-development.simplecast.com/
Banik It is such a pleasure to have you here Address, welcome to my program.
Malata Thank you.
Banik Just a few years ago, there was quite a lot of talk about the Sustainable Development Goals, SDG 3 on health. In many parts of the world there was this feeling that we all agree on the Sustainable Development Agenda, we are all going to push for this, and health is going to be very crucial going forward. Then we had the pandemic and there was a lot of worry that in Africa, oh my God, what will happen, it’s going to be a disaster and somehow it wasn't that bad. Many countries, including yours, did rather well. So, let me start by asking you a very general question, how do you see global health today? Where do you think we are making progress? Where do you think there are major challenges that we should be addressing?
Malata That’s a very interesting question, and I think maybe you ask me this at the right time because post COVID-19 a lot has changed. I want to say just going back, reflecting on what happened, I think we learned lessons and I think we also saw a lot of innovation coming out of Africa or most of the low- and medium-income countries, something that people never expected. We saw a lot of creation of ideas even the ability of universities, so at my university – Malawi University of Science and Technology (MUST), we saw students come up with hand washing machines that perhaps we would have been thinking of buying as a nation, but we were able to produce it in our own university, manufacture it and then sell on the market. We saw a lot of innovations, not just in my own institution, but all over Africa and all over the world. I think a lesson to learn is that no country should be underrated and the fact that we’re now looking into the future thinking about many things we can now do as nations, as countries on our own without always necessarily depending on someone or some other entity that seems to know things better or have resources. However, I still want to challenge us because I've seen that with global health, that we are still not moving as we should have done, and I think there's need to rethink global health. Global health, not by what we say in conferences and meetings, but what’s happening on the ground and are we giving ourselves an opportunity for those in low- and medium-income countries to be on that table, to be able to say, this is a priority in our nation, in our country, and this is how we want it to be done. I think we can't claim that we're doing well on global health if we are not able to get voices from the voiceless. Also, the issue of power, power is about money and those nations, those countries that don't have all the resources may have good ideas, but they may not be able to push their agenda because they don't have the power through money, and I want just to be very specific about money. I must also say that I think we still need to discuss decolonization, they are thinking, although in terms of discussion, a lot of discussion conferences and meetings, but the reality on the ground is that we still use one language, we're still using the same approach and as I said, later on, getting people on that table, making sure that they're able to say what they think are priorities and also making sure that we look at individual country visions. So, Malawi has malaria 2063, Africa has Agenda 2063, the Africa we want, and we all look at the United Nations Sustainable Development Goals, but when you really look at what's happening on the ground, I don't think that we are really addressing these visions accordingly, because at the end of the day, it's about who's agenda it is and what do people want to achieve with their own agenda.
Banik One of the strong arguments in favour of the Sustainable Development Goals or the 2030 Agenda was and has been that it was the most participatory process in the history of global goal setting. Unlike the Millennium Development Goals that were somehow drafted by some experts in the basement of the UN building in New York, the SDGS, was a consultative process, apparently a lot of people were consulted, so in that sense there's been this projection that this is not something that rich countries or experts have done, but everybody has formulated. However, what you point to is that really important question that is often overlooked about where are African countries in many of these agenda setting arenas? Why is the African Union left out in some of these big conferences and meetings with all the rich countries? So, could you elaborate a bit more on what you think is not working? I mean, in terms of that agenda setting, how can African countries or Malawi, or for that matter any country in the world that is not sitting around the table, what are the channels, do you think, one should make available for those needs, for those demands to be articulated better?
Malata So, I think when you look at what opportunities are there maybe it is time now that people learn to listen, because I think these voices have been there, they've come out, people have spoken about the need to really have everybody on the table, it's not happening, and it means someone is not listening. I think ability for those who make decisions and are in power to listen to the voices, because at the end of the day we want to see an impact, we want to see a change, the people that really require these services or the care that we provide, whether it's in health, agriculture, or climate issues are people who do not always have an opportunity to go out to those large meetings, their voices perhaps will never be heard by themselves, someone has to speak for them. So, creating an opportunity to listen and then also not just listening but also making sure that we really have that physical presence of those countries that can represent those that do not have a voice on the table. I think these issues need to be addressed and I think ability for someone to take that broad step to say, we need these countries on the table, and we want them on the table, and not sitting on that table and we're determining what they will eat, to say, OK, here's the menu and this is what you should eat on this menu, no, to allow them to say OK, can we see the menu and this is what we want to eat. In other words, they have priorities and then you want to make sure that their priorities are met, and they should be able to articulate. I also think that even just for they themselves to articulate their issues rather than someone speaking on their behalf, because it's quite common that people think we can speak on behalf of these particular nations, but I think that the ability to say OK, can you speak, what is it that you want? What are your priorities? Then people articulate rather than someone think OK, we know their problems, we will articulate on their behalf.
Banik So these are some of the issues you and I have been discussing over the past few days in relation to research partnerships and how to make these partnerships more equal or they should be based on equity at least, that it should not be a one-way process. Hearing you speak about this in terms of some of the voices that have been there, and you've been a very important voice for many, many years, you're a very inspiring person to very many people around the world. I wanted to ask you about the Malawian experience, if you here today Address, could say there are certain issues that I, Address Malata, would like to prioritise in the health sector in Malawi that I've been talking about for many years, but nobody is listening, what would those be? Is there something that comes to mind right away that you think can intervention, that you really think should be there but is not being funded or prioritised?
Malata Maybe sometimes people listen, but they don't listen well, or they listen and maybe they think there's nothing that can be done. I want to advocate today for health workforce, the issue of numbers, the issue of quality. We still need to train as many doctors, as many nurses and I would say just any health workforce that's required to move a health care system, the issue of numbers. So, it's not just us about training or educating them, but when you educate them, can you give them jobs? And when they get into the system, can you retain them? Because renumeration is a big issue for health workers in Africa and many parts of the world, they are not well paid, they're overworked, they're overwhelmed with the work they do. I worked on the ward many years ago and I know how tough it is for even a nurse or a midwife in a country like Malawi to work very, very difficult circumstances, many times there are no resources, even just for them to do their work well. So, I would like to speak that these need to invest more in health workforce, investing in education, investing in career pathways, investing in retention. They want to send their children to school, they want to send their children not only to school, but also to a good school and then they also want to have electricity, they want water, they want at least to have a good house and even transport in a country like Malawi, transport is a challenge and I think there's need for more investment. I think that every nation should invest and yes, because nations are at different levels in terms of financial resources that those countries or those institutions that are supporting healthcare should put resources, adequate enough to train and retain them. I want to repeat. They are overworked, they're underpaid, the renumeration is not good enough, and yet we expect so much from them. I want to say COVID 19 taught me lessons, we lost so many health workers, they worked even at the time everyone was afraid, these nurses and doctors were on our wards in clinical settings taking a risk and some died. I think for low- and medium-income country, it's not just about COVID, it's been about many issues, illnesses, non-communicable diseases, communicable diseases, are both now on the rise, in the past you will be talking about communicable diseases, but now non communicable diseases are also on the rise, issues of cancer, hypertension, diabetes are all on the rise and health workers have to deal with all these issues. I must also say that I think there's a need to invest more in primary health care, if we can ensure that people don't get ill, don't get sick, we would actually be managing a bigger issue and perhaps making more inroads rather than just looking at issues of treatment. I want also to talk about another dimension, many times when I've had an opportunity to speak about health care workforce and I speak about education because that's what I did for many years, and I continue to do. But usually people look at software, we will give you scholarships and yet the students need a good laboratory setup, they need equipment, they need real infrastructure and I’ve noticed many times when I've lobbied, people will be saying, OK, we'll give you scholarships, maybe we'll give you this opportunity for your academic members of staff to go to school, but they are not willing to build and yet you still need buildings. Of course, now we are going virtual in many ways, but we still need a laboratory where a nursing student and a medical student would be able to see. But also, for me now in my new job, we're teaching medical engineers, we are teaching students who are learning about medical microbiology virology, they need equipment, they need space, even much more now. Give a good example of my university where we have students here, we have male and female students, we are in a rural setting, I've been crying for extra hostels and more particularly for girls, and when you reach out to the partners, people seem not to move, they think it's OK, they can stay in that 20 bedded room, it's alright. But I think that there should be a change in the way we think and rethinking, how do we invest in health care workforce? Because this is a building broke, you cannot talk about good health care without health workers, without nurses, without midwives and making sure that they're also happy because we talk about their behaviour, their attitude, but many times don't talk about their own working experience, their own working environment. Then also, how do you provide even a career pathway? If they do a bunch of science in nursing, what next, and can they still get into a PhD and then remain on the clinical side like many countries do? I'm sure even in this country and in Australia where I studied where people can still go in a career pathway, and still maintain their position in the in the ward or in the clinical setting, because that's the only way you can actually balance quality of care. But in our settings many times as people get their PhD, they want to be in an office and maybe we haven't provided a very good pathway where they can advance and still keep a clinical position. These are things that perhaps people don't want to talk about, but they are the reality, and we also want to attract good students. I've seen many students that have done nursing and then they drop off and go into Medicine, that should not be the case, you can do nursing, proceed with nursing, become a professor and still do other things rather than thinking OK, if I maintain a position in nursing, probably I will not be able to get into a job that will buy me a house and we want to avoid that. So, I think there's a lot of inequalities happening that need to be addressed, because at the end of the day, it's about care, it's about quality of care, we need well trained people that can also provide good care and where they should be maintained. The issue of maintenance is very important because you see most of them, they migrate to other countries, or they stay in the country, there's internal migration, they go and work for international organisations, non-government organisations and then we leave those nations who perhaps don't have another pathway than on the ward, they may not even have passion for being on the ward, and it worries me. For me, it breaks my heart to see everybody leave when we could have kept some people on the ward.
Banik I'm reminded of a friend of ours, Paul Farmer – he passed away earlier this year, what an amazing person and life that was cut short too quickly – he inspired me a lot and I'm so grateful for his friendship. Paul was very committed to, and he told me this many times that what is important, is precisely doing the so-called unsexy stuff, which is the training. The long-term investments in training doctors and partners in health have been doing that, and it takes a long time to train so you don't get that immediate effect, but training is important. But I also wanted to pick up on what you said about infrastructure because several years ago I had the pleasure of visiting your university campus, MUST, what I was studying then and I'm still studying is among other things, Chinese infrastructure building and I think your former President recognised that, Bingu Mutharika, he wanted a university that you currently head, where you could have first rate labs where you could actually have enough space, you could create a new community. This was possible because again there was one actor, in this case, China, that was willing to go beyond just the software and build the hardware and China has been doing this in many parts of the world. What has been the impact of that? Say, the university that was built, you have the labs, I know there has been some shortage of water and certain issues related to it being quite far away from the urban centres, but that kind of infrastructure is being built by the Chinese, right? Is that something that western actors should be prioritising more of? So, in addition to giving money, in addition to helping with the budget or budget support, which also Western actors don't do much of anyway, should there be much more investments in that kind of building? Not just universities, but just health infrastructure in general.
Malata Yeah, I think so, I think you've raised a very pertinent issue about infrastructure development. I do think that there's need for all actors, so I would just say for all actors to really rethink issues of infrastructure development, it is very expensive, but it makes a difference. If you look at Malawi University of Science and Technology, it's one of the most beautiful entities in Africa for higher education, we call ourselves the warm heart for higher education, very beautiful infrastructure. But I think as you rightly noted, with some gaps, the university was built without laboratories and there was no equipment as part of the whole grant, the whole loan, so, issues of equipment, issues of infrastructure that is incomplete. We do have accommodation for just over 1000 students and yet the university should have a minimum of 5000 students. So, there were gaps and we do not know what exactly happened, but those gaps need to be filled. In other words, my message, even for those who decide to support countries with a grant or a loan, there should be completion of what was planned, because if you look at my institution, we do not have even staff houses, so every member of staff has to get into MUST every morning, it's very tiring for all of us. So, at the end of the day, one would think if you put an entity in such a rural setting, then you should make sure that you have at least housing, maybe a shop, a good hospital and we do have a hospital on campus which is empty, there was no equipment, I think now the Chinese Government is buying equipment. But my message is that there should be investment in infrastructure, and I do know that perhaps that is an expectation for countries to do it on their own, but when you look at the levels of resources that countries have, it is not always enough to do that. If you look at my country perhaps, we really haven't made so much progress on road infrastructure and received few things happening now with quite a number of roads coming up, but to me it’s late and, and maybe because it's late, we need to run as a country that we do it and not just doing it, but we do it well. So, my thinking and my push is for investment in both software and hardware.
Banik One of the many issues I wanted to talk to you about, and this is something that I've heard now for many years, these figures that Malawi trains many nurses but because of the salary issue, because of lack of opportunities, because of lack of accommodation, all these benefits that you were mentioning, many of them end up in the UK. Now, that kind of brain drain affects all countries that would face something similar, but it affects a country like Malawi even more.
Malata You really can't stop brain drain, there will always be individuals that want to go to another country. But I think that then we need to train more, so those that are getting nurses out of Malawi should be able to invest back into Malawi, so we train more. But also, I've seen that if you look at the trend in the last two decades, the numbers reduced and what changed that was the fact that the career progression in Malawi, we decided to put up a track that would ensure that nurses who had done their degrees and diplomas would be able to train in Malawi with at least master's level and PhD level. So, for the first time, I trained in Malawi, initially with a diploma and then degree and then an additional certificate in Midwifery, then went to Australia, did my Masters and PhD. But the lessons that I learned when I was studying in Australia was the fact that you really have to manage, you have family, you have children. I had to leave a two-year-old daughter with my husband and took a 10-month-old baby on the breast to Australia with me. One of the things that inspired me when I went back to Malawi to start postgraduate programmes or graduate programmes was the fact that I thought not every nurse should leave Malawi to do a PhD or a master's degree. So now at the Kamuzu College of Nursing we are part of the University of Health Sciences, and we launched six masters’ programmes within three years and then PhD programmes. I want to appreciate here colleagues in Norway that supported capacity building because we sent a number of our faculty members here to study, but we were also supported in curriculum development and support in what we initiated. But to me when I look back, the multiplier effect, we're able to train Malawi nurses at master's level not only for the College of Nursing but also for other colleges of nursing. We've been training people from other countries, Sierra Leone and Zambia that came to study at our own university, Kamuzu College of Nursing. I thought the career progression using education retained many nurses because at that time not many nurses wanted to go to the UK because they knew going into the UK that they would not go in to work and then immediately study a master’s programme. But in Malawi you were able to work and within two years you could go into a master’s programme. So, there's much progress and I must say, they can testify, that career progression is not always outsiders, but if you give people an opportunity to do their masters or PhD programme within the country, then you can retain some of them. Now I have of course seen over the past few years that trajectory has changed again, I'm seeing quite a number of nurses now beginning to go back to the UK and majority of them are not those that have done graduate studies, it’s actually those that have just done a bachelor’s degree and mainly it's because of unemployment because we have not been able to absorb everyone who has trained. Therefore, that pushes me to look at the issue of budget, as the government puts up a budget, there should be resources for recruitment because I think the young many times get frustrated, they would rather get out of Malawi, pick a job elsewhere rather than sit at home and then they don't have a job because I think we also like flooding the system. International organisations, non-government organisations can only absorb a certain number of nurses. So, you see that quite a number of nurses that have been sitting at home, sometimes even three years without getting a job, and therefore we're now seeing the shift that some are living, and I know that because I still have to give references for a number of nurses that want to leave the country. So, retention and then ability to recruit them when they have finished their studies and then give them a career pathway. There are nurses who are just are happy if they do a master’s degree, they may not get as much money, even when they do a PhD programme, they go through a PhD programme, they graduate, they are within the system and we also have seen some of them taking leadership positions because of their PhD qualifications.
Banik Malawi and many other countries did far better during the pandemic than was expected, and there are all kinds of reasons, I've talked to many of your colleagues like Titus Divala and many others who pointed to the fact that well, frankly, Malawi had quite a lot of experience with infectious diseases. Malawi has a young population; there were lots of factors that helped Malawi succeed quite well in the first year, it was only during the second or third waves that things got pretty bad. So, on the one hand you have these successes that were perhaps seen by many in the West to be highly unlikely, but nonetheless successes in terms of HIV, Malawi has often been hailed as a success story, life expectancy at birth has increased for both men and women, many of the Millennium Development Goals were reached. So, you have those successes and yet we know there are many, many challenges in the formal sector. How do you enforce a quarantine when people have to go out to earn a living? You can't just stay in the luxury of their homes and then, as you've already mentioned, the lack of adequate budget for health. Added to all of this is the whole the availability of drugs in the country and how difficult it is to procure; I direct a project looking at how Indian companies are supplying drugs to Malawi and some of the challenges Malawi faces. So, in a nutshell, how would you describe the health sector in Malawi today, both in terms of what is working and where you think there is a need for additional expertise and knowledge but also finance?
Malata The observations you've made are right. I do think that Malawi is an interesting country because when you look at what's happened, we have tangible examples, how we have managed to really work on HIV and AIDS, prevention of mother to child transmission, I think we're one of the countries that made decisions and implemented what really worked for Malawi and then was used by many countries. I must also say when you look at education, I think area owners talking about the challenges about education, but I think we have made progress. I think for medicine, our programme in Malawi is really an outstanding programme, it's received a lot of approvals and people are appreciating that Malawi has been able to produce the graduates who are now mostly specialists and running the health care system in Malawi. Then of course, nursing too, I think the College of Nursing was one of the largest in Africa and also training people at different levels, you certainly have very good examples there. I must also say that on the policy side Malawi's health system, we've been able to develop policies, policies for managing the different types of diseases, noncommunicable diseases, communicable diseases, and the whole spectrum, we've been able to do that very well as a nation. To me, what I see as a challenge is just that the issues are overwhelming, but you are right in that during COVID-19, we showed that it was possible to manage COVID-19, I think experience in infectious diseases helped the nation and I think third wave was just because it was really just too much for a country like Malawi with the numbers and then migration, people returning to Malawi from other countries and then of course, the resources being very few because we there was so many issues with the travel and flights into Malawi and out of Malawi. But I think we still did the best, I think if one documents a story about COVID-19 we would have a very good example. Then we saw innovations in countries and universities coming up with innovations. I do think perhaps areas that we need to work on is manufacturing, because we are still buying nearly every drug, is it possible to manufacture some of the drugs in Malawi? And I think it can be done. I have a young scientist who trained in the UK and is back in Malawi at my university, and I know that he does a lot of work in issues of drugs and making tablets, so I've been discussing with him that I think it's high time we started manufacturing. Even manufacturing equipment, MUST is offering a programme in medical engineering, and biomedical engineering so medical devices can we start manufacturing in Malawi. I have already seen some devices in my university and also the new mobile switches which used to be polytechnic. At the moment, we’re trying devices from other countries, but I have seen a lot of innovation coming out of our students because we could actually come up with devices that we manufacture starting with prototypes and then if we get approvals, we go into commercialization. I think it's high time our country went into manufacturing because we are importing everything, and Forex is a big issue now. I think you have been following, so if we are buying everything then certainly the country will struggle, but I think moving forward and actually I have passion now that I'm reading investment of science and technology on medical devices and I think that it can be done, I've seen what students are doing, if we can even just get one device done in Malawi and then we export, I think things will change. I've talked about the workforce quite a lot, but I also thought maybe we need to look at primary health care and start reinvesting in primary health care and so we take health care to the people much more than what we've done because I think we were pulling everyone. I'm a maternal health expert, we are saying every woman should deliver in a ward in a hospital, but when they come there, quality of care is a big challenge because the system doesn't have adequate space, doesn't have adequate equipment, and yet we could have allowed these women to deliver, maybe in in a health care facility that's smaller in a rural place in Malawi. But I have a very sad story and that really has changed the way I think because there was a time, I was doing a study on why women died and so I went out to rural Malawi, it was supported by the World Bank, I had colleagues working with me from John Hopkins, we went out to rural Malawi and this one particular story changed my life and changed the way I think. We found a woman who was mourning her daughter and she told us a story that her daughter was in labour and she told me personally that she thought her daughter was healthy, she said she didn't have any issues, she was in labour, they went to health facilities, a small health facility, I would not mention the district, but they waited for three days to get an ambulance when they noted that labour was prolonged and then after three days the ambulance came, they went into a District Hospital and then in that District Hospital their daughter died on arrival. She said I was called in the labour ward, and I could see the baby still kicking and asked the nurses and doctors whether they could remove the baby and they said they couldn't do anything at that point. So, her daughter died and so she posed the question to me that when her daughter died within minutes there was an ambulance to take them back to their village and so she asked me, why is it that when my daughter was in labour we waited for three days and when my daughter died, there was transport immediately and I cried, I broke down because I failed in the 21st century, that should not happen. It means that there's certain things that are not working well. So, maybe we need to look at our referral system, we need to look at making sure there's transport and of course there’s always issues about road infrastructure, but I think there's a lot happening now in terms of road infrastructure. But to me, the ability for people to say, there's an emergency here, let's drop everything, let's get these people into a better facility and then, if necessary, a caesarean birth is done if there's need for that. Rather than, keeping someone for three days and then they die, and then when they die you are saying here is transport. It left me with a lot of issues and its quite many years ago, but it's changed the way I think because I don't think that people must get to that point where you don't provide quality care and quality services and I have still not found an answer for that woman because I thought that I left her without an answer and so these questions still ring. To me it's a wakeup call that maybe we need to look at our priorities, making sure that we have resources at every level of health care, not just at perhaps our tertiary institutions, the tertiary institutions in Malawi have entered a growth. Like one central hospital in a region is not good enough, I do think that we need to expand that surface, so it gets back to the issue of infrastructure. Can we have two central hospitals, perhaps next to each other, so that if one hospital is overwhelmed, another hospital can take care of that, and then the district hospitals, we upgrade them so that they have every service that's required and then we have specialists everywhere because the specialist numbers are still low, so they need to still train more specialists. But then there is the issue of equipment, equipment is a big issue because even now as I speak, we have times when people go into a facility and then they just want to have a check-up, they want to have a biopsy taken, maybe suspected breast cancer, it takes weeks before people know whether they have breast cancer or not. I have a woman that I supported, she went in, and we waited six weeks and when she went back, she had third stage breast cancer and she survived, but my thinking is that that should not be the case. Let's have diagnostic services and I think if there's an area that needs investment its diagnostics. I'm not just talking about you go Lilongwe and then you can go for this test, I'm saying can we have diagnostic services in every district so that if people are suspicious they can go in but they don't have to give a specimen and then wait for weeks without knowing the outcome and those who can afford would be able to fly into South Africa, fly to India, or they have an insurance, but a local individual who doesn't have any resources, the chances are high that they would die quickly because they were not able to get that service.
Banik You've raised so many interesting issues. Let me reflect on some of those because it relates directly to some of my current research projects. On the issue of procurement, which I alluded to earlier, there are certain bureaucratic hurdles, not just in Malawi, but also elsewhere, it is also related to the lack of foreign exchange, it has to do mainly also with how large the domestic market is. Manufacturing is something I hear a lot of African policymakers say they want, but when I talk to Chinese or Indian companies working in Malawi, working elsewhere on the African continent, they say it depends, Nigeria and Kenya big market, South Africa big market, Malawi is so small that local manufacturing is not viable, so yes, you could make paracetamol that some locals produce actually in Malawi, but for higher end products for increasingly lifestyle diseases etc, they're so expensive but the market is so small it is actually cheaper to produce in India or China, elsewhere and then ship it than to produce. The same thing actually goes for devices, but I like your point about how universities such as yours could actually play a very important role and now come to think of it, I used to read in the Nation and in the Daily Times, the two major newspapers in Malawi during the pandemic, how many of your students were very innovative, especially in relation to devising these hand wash machines, or it could be a simple bucket, or a bit more advanced hand sanitizer dispensing machines. So, there's certainly a lot of opportunity, but I wanted to get back to this issue of care and a lot of my friends often jokingly, perhaps not so jokingly, say that we can be sick when we go into a hospital, but when we come out, we're even more sick. It is this kind of frustration with what is available, and it is not just the poor, it also affects the topmost politicians, it could affect the president. As was the case with former President Mutharika, who could not receive the kind of treatment he wanted because there was no equipment or something that was not available and so a lot of the elites end up going to South Africa to India, medical tourism from Africa is increasing and many Indian companies are making quite a lot of money because of medical tourism. So, you see all of this is happening and yet there is, in my view, a lack of emphasis on doing the basics, there is a lack of emphasis on allocating enough resources for the preventive aspects, there's always this focus of the curative. So, in terms of, say, the example of the woman you mentioned, it is a very, very sad story that we sometimes are perhaps more efficient in areas where we should not be focusing that much on, even though providing the ambulance to take the body home is an important part, but preventing that death from happening should have been the focus. In your work and also in other works I've read that some of the challenges in terms of maternal health relate to the delays in actually bringing a person to a healthcare worker’s attention or to a hospital, there could be family related issues, there could be the distance as you said, the infrastructure. That's one set of issues and then the second has to do with when you do come and there is an inadequate infrastructure in the hospitals and so I've noticed that you've been, in your writings, been arguing about care and the different sort of ideas of care. Perhaps you could say a little bit about that kind of work? Where do you think we should be, not just doing more research on, but where should the money be provided as you were saying earlier, it isn't the rural healthcare centres, maybe not just in the urban centres. What else should we be thinking about? Because I'm told there are certain domains here, right? Could you highlight some of those important domains in relation to care as you see it?
Malata It's also very critical to know that a lot has changed over the years. I think for me when you look at the domains, the fact that when you look at the three delays, delays about making a decision whether somebody should go to the hospital, I can now argue that if you go out into rural Malawi today the Chiefs, the Community leaders, have now understood the fact that a woman or a baby or any sick person should not be delayed because of perhaps their beliefs, because there was always that belief that maybe before a woman is taken into the hospital, the uncle should say yes, it does happen here and there, but overall, I think there's a general understanding now that if people are not well, they need to get a service. Then also the fact that the health surveillance assistants who work in the rural area are providing some information to say maybe if this happens is what you’re supposed to do, this is how we prevent cholera, this is how we prevent COVID, we have all these health workers that are working in the rural setting. I think the second delay is when they are in a facility, what happens, this is where we still need to push in more resources and more effort and perhaps even issues of policies. These systems are overwhelmed, that's still a big issue, there are a lot of number of patients that will be coming in, so the numbers are huge with limited resources. I went out with a facility a few months ago with a partner, we are working on family planning and so we decided to go into Lilongwe into one of the facilities to look at women that had come that morning for family planning. I was shocked. The women were standing in the court, many of them waiting even just to be registered. So, I asked the nurse and midwife whether they could rethink the way they provided services, do all these women have to come at the same time? Perhaps women who are studying a service could come in the morning, and those that are coming in maybe for a refill or something could come in the afternoon, so you don't see them overcrowded like that, and she laughed about it. But I've been reflecting on the fact that maybe we need to change policies on the way we provide care and so there might be need to look at some of our policies so that we decongest our systems.
Banik Because it's not always about the money, is it?
Malata No, it's not always about the money, it's about just looking at how a service is provided. In one of our studies, we are looking at can we have women come at different times? So those who are coming for the first time they come in the morning and those that need to just come for a refill or perhaps to ask questions, they come in the afternoon so that you don't have women standing in the court, so it's not always about money. I want to also argue there that I think many times everybody pushes the issue of health care, because of money, it's not always about money. Sometimes it's about policies, it's about leadership. I also believe that if you have a very good leader in a facility and that's very progressive and transformational, they will change certain things and you actually go into a facility and you can appreciate that the fact that things are happening well. So, I do believe that in the arguments in those of my papers, I think you've seen, I've been pushing for leadership, transformation leadership where we train health workers and train anybody who's going to work in public service. We look at how can they make a difference in a setting, by the way they think, the way they organise themselves, the way they do things to make sure that even the recipients of care will want to come back because there are times when people come into a facility and they're not happy with the service, they will not come back and you find certain facilities are actually very busy, other facilities nearby are not very busy because people have gone and they're not satisfied with the care they receive, and then decide, let me go elsewhere. So, I do think this needs to have a policy shift on the way care is provided, let's look at new innovations, let's look at how we can ensure that we're giving care that is satisfying and that our clients should be able to look back and say it was worthwhile going to that particular facility.
Banik Because, sometimes I feel that much of the care, not just in Malawi, but in many other countries is characterised by arrogance, it's almost like you are supposed to be grateful, it's not your right, we are being generous, we are being benevolent, that's why you're getting it, and that's why you should wait for a long time outside the office, because the doctor is too busy and there is no system. But in many other countries there's much more use of mobile health, using the mobile phones like in Kenya to schedule an appointment. So, there is technology available, and a lot of people have mobile phones these days, so there's a different way of doing it, so I really sympathise with that argument you're making. Another example, not related to health, that I often think about every time I land in Chileka airport in Blantyre, it's a small airport and obviously it would help to have a bigger airport, more money is required, but in the meantime, while one is waiting for a bigger airport, there are ways in which those rooms that are there could be better designed to make things more efficient. I've been interacting with the Foreign Service and many of the civil servants, how do you design the luggage area or the visa section, you could free up a lot of space, make it more effective. So, I think those are just examples of how things can be done without really always thinking about the money. But talking about the money, because some of these hospitals Address, are underfunded, I see a new trend in Malawi, because you have a growing middle class or as you would say, elites you either have poor and then you have the rich well-off groups who get a monthly salary, work for international organisations, donors etc. They are now able to access a different sort of health in some of the hospitals, so you have the free service and then you can pay for certain things. Am I not right that there's like a two-track option, so you could buy yourself better healthcare and skip the queue if you have money?
Malata Yeah it does happen, but I must say it’s illegal, it's not right, and it's unfortunate that it happens. I do know that many times when people have flagged this issue, there's usually some feedback from those in authority to say this is not right. So, for example, if a lift is not working and then people want to be moved to the third level or fourth level, they pay to some people to carry them there. But I must say, overall, that some of the illegal practises people know, and then I think they've been condemned but also, I must say that this is something that we need to discourage, because then the gap between the poor and the rich widens. I would rather we improve the service so that as many people get quality of care. I also believe that every individual needs to feel uncomfortable when such things are happening. I think we should not trial because even if we trial these behaviours, we are actually damaging our nation and not just for now but also for the future and then the young people of Malawi will think that's normal, it is not normal, it's not right. Everyone should give receive the type of care that's available. So, if anything, we need to work on improving the quality of care so that everybody should feel comfortable to go into any facility and be aware that they will be able to get good care. I want to give you an example here, I lost an in law a couple of months ago, we could have taken him to a paying facility, but we took him to a non-paying facility in Lilongwe I was very impressed despite the fact that there was inadequate space, inadequate equipment, but I was really impressed with what the nurses and doctors were able to do with their limited resources and I said to myself, I wish we invested more in these facilities because we lost him because things were just beyond what the hospital could do but I wouldn't complain that he did not get good care and that's what you want to see. I'm sure people were surprised that he actually died in that hospital because they thought perhaps we could have put him in another hospital. But I must confess here that I was just impressed with even the speed and the decision making and ability for doctors say let's try this, let's do that, and that's what we want to see for every Malawian.
Banik I think that's a very good point because I think we have to have hospitals where leaders feel that they can get good treatment and citizens should actually see their leader's getting treatment in that hospital so that they know that these leaders are not going to go to South Africa or India or somewhere else. Like Robert Mugabe, he would never get treatment in Zimbabwe, he was always going to Singapore and that does not create much trust in the local system. But is it a case that in in countries like Malawi, is the government, not prioritising enough, or not providing money, or is it that they want to provide money but they don't have enough?
Malata I think there are competing priorities because you know, agriculture is a big issue for Malawi, we are, dependent on our maize and tobacco and other things. So, education is another priority for Malawi, and we have a huge educational system with primary, secondary, and higher education, so the demands are huge. Then you look at health, another big issue we are dealing with two entities of health care, we are looking at infectious diseases, non-infectious diseases and then of course something like COVID comes on board at the time you're not expecting. I sympathise with the government because I think the resources are not adequate, but at the same time, the government has to move, and things have to change for every sector. But to me, sometimes I just look at, this is regular, you're looking at a young person who is carrying a very big basket on their head and you can see them struggle to walk not because they don't want to work, but I think the issues are just too much. I think Malawi has got very comprehensive issues, but also, it's quite overwhelming. But I also believe that there has to be that desire from every sector, whether it's our leaders or non-political leaders and everybody just being on board and making the decision, let's see things change. It means really tackling every issue that would ensure that resources are used rightly and that there is good portioning of resources and then for those partners that support our country look at how Malawi is struggling and how we are trying to deal with issues and to say look maybe this sector we can support you. I do know that they would always look at accountability issues, which is normal, but I think that willingness on part of those in leadership, those who are not in leadership, every citizen really just says we want to see things change. I think for countries like your own country to be where you are, it took decades and therefore it might also be important that people should be patient sometimes to say OK, look, maybe this particular project did not go very well, what do we need to change? Can we deflect openly to say this you did not do well and maybe hear ourselves, what were the issues and then to say OK, moving forward what can we do? Maybe shift the way this thing is done so that we can actually see a positive movement.
Banik Well, I totally agree with you, patience is important, the long term is important, and these are things that you and I were talking about. As you mentioned a few days ago, these are the messages we have for the Research Council of Norway, these are the messages we have for the Norwegian Government as we have for anybody really listening. I want to ask you one final set of questions Address, this relates to your personal career, your meteoric rise, your success as a pioneer, you've been the first of many things in terms of having leadership positions, heading universities and often being the only woman, perhaps in the room, usually these rooms in Malawi, as in many other parts of the world, are full of males. How would you characterise your journey so far, of your academic career, your leadership positions, your international honours, your honorary doctorate, your ability to work as you said, with many regimes in Malawi? What has been the experience so far, and where do you see improvement in terms of getting a better, more balanced gendered workplace? Because it is still a big challenge, isn't it? In Malawi to get women up to the level that you are in we need many more Address Malatas.
Malata Yes, so my journey has been both inspiring but also challenging. I think challenging because indeed when you are first then you have to really clear everything on the on the pathway. I normally laugh that even today, if I left my position, probably many more people will apply because I think starting a university from .03 programmes today we have close to 40 programmes and then PhD holders were 3 and now we have over 50 PhD holders, the same in my previous job in the College of Nursing, very few PhD holders at beginning, I left the College of Nursing with 60 PhD holders and so I've seen the power of starting things, it's very challenging. It also challenges the way you think, I have had to learn to be innovative but also to rely on networks and partnerships and really get sometimes things done quickly. I think in terms of Oslo we send 6 nurses here and today they are in leadership in Malawi. I also believe that as women we do double what perhaps men would do and then you are leading in that boardroom. So, I've also had opportunities to be on different boards, both national and regional, as well as international boards. Actually, I want to share an experience where I was the first midwife from Africa to become Vice President of the International Confederation of Midwives. So, they vote for you, I think, it was in a European country and I'm seeing the electronic voting there was so much jubilation amongst midwives in Africa. So, for me then the question you're raising is I do believe that we should have many Address Malatas in the pipeline so that when I'm not there, somebody should be able to take the position and do the work, maybe much better than I did, which I think is the challenge. Malawi has made progress, I think when you look at Malawi now, most of the senior positions so like in the police, ACB, ombudsman.
Banik You have Martha, you have Grace, you have all of these.
Malata Yes, all these people that have taken leadership and then we have Dorothy at Malawi National Examination Board. But the question is, when they have finished their work, would we be able to have another woman take that position? We should also create an opportunity for women to start growing even much, much earlier in their lives. Some of us were mentored by perhaps external partners, Professor Johanne Sundby from here, the University of Oslo took me by the hand, and I remember when she first met me she said look, I'm a very seasoned professor, so I don't necessarily need papers, but I want you to become a professor and she managed to do that, so I was actually mentored by her, and she's not even a nurse she’s an obstetrician. We need to have that, it's beyond mentorship, an opportunity to create this pipeline and the pipeline should not start at higher education, it should start at pre-primary, primary education, secondary education, higher education. Although I celebrate women leadership in Malawi, but the lesson about ICM, when I left it was taken back to Europe, gave me some lessons that it should have been a case where when I finished my term, another African midwife should have taken over or somebody from Asia should have taken over immediately. So, the pipeline issue is a big issue. But I also want to say that it's about investment, we need to invest in girl education, not just about girls starting school but maintaining them in school because in Malawi when you look at our data they start well but in higher primary they drop off because they now become adolescents and then the facilities are not good enough, so they will skip days when they're in menstruation, already they are losing time to learn and then so when you see that pool going into secondary school, the numbers are already getting raw and it is so thin when it comes to higher education. Number two, it is also about making sure that fees are paid for, and so I'm one of those people, if you look at what I do in Malawi is I've run for fees, there's no bank that doesn't know me, I've been to every sector insurance companies to plead for fees because if this girl is coming from a rural setting, no one is there to pay fees for them when they come in, chances are high they'll get married to another male student who is well off and then, if that doesn't happen they just drop off, they don't come back. But also, as an African woman balancing you are a wife; you are a mother, you are a daughter, you are a sister, you are a community leader, I do a lot of preaching in churches, so how do I balance? Many times, that's the question I get, how have you managed? Because it's been years of leading, but I do have a very satisfying marriage, a husband who sometimes asks me, there's this opportunity why are you not trying it? Sometimes I'm asked to serve on a board and then he says, oh, this is good, but I don't know about this particular one, he says no you have to learn you have to do a course in banking for finance for non-finance managers because you can't sit on this board without understanding these issues. So, if you have a partner like my husband who is very supportive it helps, but then there are other partners who don't support, so I need to help these women understand that you may not have a good partner, but this is how you navigate the journey. The reason why we started graduate programs for nurses, masters and PhD was that I do think that the nurses and midwives in Malawi are very intelligent, very capable and I would want to see them still occupying positions. We have the Director for HIV, Director for sexual reproductive health, they are all nurses, I do believe that the heartbeat for health care in any country is nurses and midwives, so can they be on the table? But then for the same time for any socioeconomic development, give them an opportunity, women will always make a difference because they don't think about themselves, they want to leave a legacy. In what I do myself, I've dedicated my life to make a difference, so when I'm not there I don't want people to remember me as Vice Chancellor, First Woman or first whatever, I want people to say this is the difference she made.
Banik Address it was such a pleasure to have you visit my home today. I know that I had a great time chatting with you, but my family also enjoyed meeting you very much. Thank you so much for coming on my program.
Malata It's really been a pleasure and thank you for inviting me to be on this program.