I have been an employee of the University of Malawi College of Medicine for about ten years now. I started as an Assistant Lecturer (tutor) and only managed to move up to being a lecturer five years later, after I had completed my postgraduate training. In fact, the word “complete” is a misnomer as it is virtually impossible to complete postgraduate education in any real sense. Maybe I should have just said “after I had completed the training which was required to get me an appointment as a lecturer in community and public health.” For the past few years, I have been thinking about what my career would be if I remained in the same position for several years, serving my country, my family, and the patients whom I may be able to see during the limited time that I have for clinical responsibilities.

There is no doubt that my perception of a physician’s life in Africa and those who leave the continent for “greener” pastures has changed. I still remain committed to serving my nation and spending the remaining 20 or so years of my tenure at the Malawi College of Medicine. I am, however, less critical and less judgmental toward my compatriots who leave the country in search of a better life for themselves and their families. This is what has been dubbed the “brain drain” (1,2) of human resources for health. Several years ago, I would look at my compatriots who jumped the boat and sailed northwards or westwards as “motivated by greed and being less patriotic.” Currently, however, I see physicians who leave Malawi as people who are responding to “events in their lives.” It is also important to recognize that this may not necessarily be always a loss to the nation.

Although my perception of colleagues who leave the country for “greener pastures” has changed, what has not changed is the enormous expense and burden that their leaving places on the Malawi health system. Most of them leave the country hoping that they will be away for only a few years – until they obtain a specialist training. However, as Biblical story of Jews in Egypt says: “A new king who did not know of Joseph arose on Egypt.” (Exodus 1:8), ie, life does not pause while waiting for the Malawian physician who is abroad. Until they attain the specialist qualification, their family grows or they marry in the host country, the children are no longer in kindergarten or primary education, the mentors they relied back home have moved, and governments have changed.

As it has been reported elsewhere (3-5) that, until 1991, Malawi had no medical school of its own. Interestingly, Dr Hastings Kamuzu Banda, who was president of the country from 1966 to 1992, was a medical doctor. The argument which has been used to explain what had prevented the country from having its own doctors included the same and “lame” one – that a poor country cannot afford to have a medical school of its own. In other words, this meant that poor people in Malawi did not deserve the best possible medical care. I would like to be realistic too. Medical education is expensive and possibly very few academic programs cost as much as medical education. My colleagues and I have also documented how much money medical education costs the country and how much financial losses the country incurs when a single physician who was trained in the country leaves (6). In fact, after we had published our estimates, I received an email from a World Bank researcher who suggested that our research team had in fact underestimated the losses. We had not factored into the calculation all the costs of running a medical school in Malawi.

The successes and challenges that medical education faces in Malawi have been documented elsewhere (3-5). Let me start with the successes. The first was the very establishment of the medical school. The skepticism of the 1970s and 1980s turned into the optimism of the 1990s: Malawi currently boasts of its own medical school. In fact, the people who had argued that poor countries need not have their own medical schools were just wrong. Many countries have medical schools. There are medical schools in Kabul (Afghanistan), Luanda (Angola), Harare (Zimbabwe), Lusaka (Zambia), and Maputo (Mozambique). The argument that a country must wait until its gross domestic product exceeds a certain number is just wrong. However, it would also be foolhardy to imagine that a country could establish a medical school without due consideration of the enormous financial cost such an undertaking would require.

The second success, apart from the fact that the country actually does have a medical school, is that many of the graduates from Malawi’s medical school are still in the country. Others are in training abroad and, as a rule, Malawians who obtain further training in the African region or the United States, return home upon completion of their studies. The situation is different with the United Kingdom. Malawian physicians often have difficulties to return home after specialists training in that country.

The third success of Malawi’s medical training is what Ziljstra and Broadhead have reported in their paper published in Human Resources for Health journal (7). There has been a drive to ensure that national physicians who return from training abroad are provided the space and the opportunities to “grow” in their careers. Many are in leadership positions and others are looking forward to returning to fill up these posts.

One of the basic founding assumptions of Malawi College of Medicine was that it was to focus on the training of Malawian doctors, but also to contribute to the improvement of the human resources problem in the whole southern African region. Although in the minority, the College of Medicine has accepted students from Lesotho, Zimbabwe, and other countries. These foreign students pay full tuition and other fees, while Malawian nationals pay a token of € 160 per year for a full board. The provision of affordable education to Malawians but also the concern for the training of other African nationals is a success.

Recently, the Malawi Medical Journal published a very instructive interview with Ed Ziljstra, an Internal Medicine Professor and a Dutch national, who at the time of the interview was Chair of (Internal) Medicine at the College of Medicine. Among the many issues that were brought up in the interview was the statement by Prof. Ziljstra (8): “From the original 9 Dutch medical specialists now only 2 remain. If I am not mistaken, with my departure there are no full time academics left who hold the rank of full professor, except for the principal himself. This worries me, but it should not be seen as ominous sign; it is just the way things are developing and hopefully there will be a better balance in the future.”

Prof. Ziljstra and Robin Broadhead, pediatrician and current Principal of the College of Medicine, are the remaining full professors at the medical school. Within the institution, there is a host of associate professors and none has advanced academically in the past five years. Yet, the institution’s requirements for advancement are the same as in many other universities, ie, scholarly productivity, teaching and mentoring, and community contributions or service. One explanation for such a situation comes from an earlier issue of the Malawi Medical Journal. Gondwe and Kavinya (9) reported on the increase in the number of articles published in peer-reviewed and indexed journals by researchers from Malawi. I have responded to Gondwe and Kavinya’s concerns and highlighted the fact that the country needs to mobilize resources for health research (10). In a previous article, I also wrote about the situation at the Kamuzu College of Nursing, the main nursing university campus in Malawi (11).

Partnerships with expatriates must be pursued but not over-reliance and parasitic tendencies. By parasitic tendencies, I mean the all-too-familiar situation when nationals of low-income countries fail to submit research grants for funding but want to participate in research projects designed by expatriate researchers. While the absolute number of papers published each year from Malawi may have increased, the per capita productivity may have decreased. In any case, many of the published papers have no “career advancement value” in the strictest sense, as they are being published by people who either have reached the pinnacle of university promotions or are ineligible to be promoted because they work outside of academia or are not affiliated with the College of Medicine.

What then is the way forward? Malawi’s local health research enterprise is expanding, but not to an extent that it would allow nationals to rise up the academic ranks. Much of the research continues to be driven by expatriate researchers. I reiterate in this essay that it has never been the intention of the Malawi College of Medicine to dominate the faculty with nationals or to discourage international research collaborations. But despite the growth in research, it appears that very few people, both nationals and non-nationals, are unable to break the ceiling that prevents them from accessing the highest position in the Academia, ie, the position of a full professor. College of Medicine should find a solution how it can rise up to the same level as peer medical schools. Having just one full professor for an entire medical school is not good enough. But we also cannot allow people to advance if they still have mediocre research productivity!