DOCTORAL (PhD.) THESIS Occupational Stress and Burnout among Clinical Officers at Public Hospitals in Malawi: Impact Shifting to the General Public Paliani Chinguwo E-mail : palianic2011@gmail.com Supervisors: Dr Rajohane Matshiditsho (late), Dr Ben Scully & Prof. Bridget Kenny Submitted to the Faculty of Humanities at the University of Witwatersrand, in fulfilment of the requirements of a doctoral degree (PhD) in Sociology 10 August 2023 mailto:palianic2011@gmail.com ii Table of contents Page Declaration ....................................................................................................................................................... vi Abstract ............................................................................................................................................................ vii Dedication ........................................................................................................................................................ ix Acknowledgements .......................................................................................................................................... x List of abbreviations & acronyms .................................................................................................................. xi List of Figures .................................................................................................................................................. xii List of tables.................................................................................................................................................... xiii Chapter 1 ............................................................................................................................. 1 Introduction ......................................................................................................................... 1 1.1. Background .......................................................................................................................................... 1 1.2. Problem statement .............................................................................................................................. 3 1.2.1. Aim of the study .......................................................................................................................... 5 1.3. Rationale for choice of a country and subjects ................................................................................ 7 1.4. Overview of the methodology ............................................................................................................ 8 1.5. Significance of the study .................................................................................................................... 9 1.6. Location and structure of the thesis ................................................................................................ 14 1.7. Summary ............................................................................................................................................ 17 Chapter 2 ........................................................................................................................... 18 Setting the context ............................................................................................................ 18 2.1. Introduction ........................................................................................................................................ 18 2.2. Socio-economic context ................................................................................................................... 18 2.3. Administrative context ...................................................................................................................... 19 2.4. The architecture of healthcare services in Malawi ......................................................................... 23 2.4.1. The organisation of healthcare services ................................................................................ 23 2.4.2. Location of clinical officers in healthcare service delivery ................................................... 25 2.4.3. Social dialogue in the health sector ........................................................................................ 28 2.5. Summary ............................................................................................................................................ 30 Chapter 3 ........................................................................................................................... 32 Literature review ............................................................................................................... 32 3.1. Introduction ........................................................................................................................................ 32 3.2. The conceptualisation of occupational safety & health ................................................................. 32 3.2.1. Evolution of Occupational safety and health ......................................................................... 34 3.3. Occupational stress and burnout among health workers .............................................................. 41 3.3.1. Contributing factors to occupational stress and burnout ..................................................... 42 3.3.2. Consequences of occupational stress and burnout .............................................................. 50 3.4. Psychosocial risk management ....................................................................................................... 51 3.4.1. ILO guidelines on OSH management systems ....................................................................... 52 3.4.2. Framework for risk assessment of psychosocial hazards .................................................... 52 3.5. Narrow framing of OSH in Malawi .................................................................................................... 54 3.5.1. Clinical officers in Malawi ........................................................................................................ 55 3.6. Theoretical framework ...................................................................................................................... 58 3.6.1. Attribution theory ...................................................................................................................... 59 iii 3.6.2. Job demands-resources (JD-R) model ................................................................................... 64 3.6.3. Fundamental cause theory....................................................................................................... 66 3.7. Summary ............................................................................................................................................ 67 Chapter 4 ........................................................................................................................... 69 Methodology...................................................................................................................... 69 4.1. Introduction ........................................................................................................................................ 69 4.2. Research Philosophy ........................................................................................................................ 69 4.2.1. Interpretivism ............................................................................................................................ 69 4.2.2. Philosophical assumptions...................................................................................................... 70 4.3. Research approach ........................................................................................................................... 72 4.4. Research design ................................................................................................................................ 73 4.4.1. Qualitative explanatory approach ........................................................................................... 73 4.4.2. Research strategy ..................................................................................................................... 73 4.4.3. Time horizon.............................................................................................................................. 74 4.5. Methods of data collection ............................................................................................................... 74 4.5.1. Virtual interviews ...................................................................................................................... 75 4.5.2. Virtual focus group discussions ............................................................................................. 77 4.5.3. Document analysis ................................................................................................................... 77 4.5.4. Advantages of positionality ..................................................................................................... 78 4.6. Study sites ......................................................................................................................................... 79 4.7. Study sample ..................................................................................................................................... 81 4.7.1. Sampling procedures ............................................................................................................... 82 4.7.2. Sample limitations .................................................................................................................... 84 4.8. Methods of data analysis .................................................................................................................. 87 4.8.1. Thematic analysis ..................................................................................................................... 87 4.8.2. Reliability and validity .............................................................................................................. 88 4.9. Ethical considerations ...................................................................................................................... 90 4.10. Summary ............................................................................................................................................ 92 Chapter 5 ........................................................................................................................... 93 Occupational stress and burnout at public hospitals before COVID-19 pandemic ...... 93 5.1. Introduction .............................................................................................................................................. 93 5.2. Excessive workload and long hours of work .................................................................................. 94 5.2.1. Impact on occupational stress and burnout........................................................................... 96 5.3. Poor inter-professional relations ..................................................................................................... 99 5.3.1. Impact on occupational stress and burnout......................................................................... 104 5.4. Discussion ....................................................................................................................................... 105 5.4.1. Excessive workloads and long hours of work ..................................................................... 105 5.4.2. Inter-professional conflicts .................................................................................................... 113 5.5. Summary .......................................................................................................................................... 116 Chapter 6 ......................................................................................................................... 117 Restructuring in the health sector before the COVID-19 pandemic emerged ............. 117 6.1. Introduction ............................................................................................................................................ 117 6.2. Restructuring ................................................................................................................................... 117 6.2.1. Decentralisation ...................................................................................................................... 118 iv 6.2.2. Emergency Human Resources Programme ......................................................................... 120 6.2.3. Functional reviews .................................................................................................................. 124 6.3. Impact on occupational stress and burnout ................................................................................. 127 6.4. Discussion ....................................................................................................................................... 136 6.4.1. Power ....................................................................................................................................... 136 6.4.2. Identity crisis ........................................................................................................................... 140 6.4.3. Task shifting: source of occupational stress ....................................................................... 142 6.5. Summary .......................................................................................................................................... 143 Chapter 7 ......................................................................................................................... 144 Occupational stress and burnout at public hospitals during the COVID-19 pandemic ......................................................................................................................................... 144 7.1. Introduction ...................................................................................................................................... 144 7.2. National COVID-19 responses ........................................................................................................ 145 7.2.1. Re-organisation of work at public hospitals......................................................................... 148 7.3. Impact on occupational stress and burnout ............................................................................. 152 7.4. Discussion ....................................................................................................................................... 166 7.4.1. Mentally unprepared to respond to the COVID-19 pandemic ..................................................... 166 7.4.2. Reorganisation of work at public hospitals ................................................................................. 167 7.4.3. Shortcuts on health and safety requirements ............................................................................. 168 7.5. Summary .......................................................................................................................................... 170 Chapter 8 ......................................................................................................................... 171 Policy and theoretical perspectives on occupational stress & burnout at public hospitals .......................................................................................................................... 171 8.1. Introduction ...................................................................................................................................... 171 8.2. Occupational safety and health (OSH) management system ...................................................... 172 8.2.1. Policy ....................................................................................................................................... 174 8.2.2. Organising ............................................................................................................................... 176 8.2.3. Planning & implementation .................................................................................................... 177 8.2.4. Evaluation ................................................................................................................................ 177 8.3. Discussion ....................................................................................................................................... 178 8.3.1. Poor safety culture ................................................................................................................. 178 8.3.2. Framework for a comprehensive OSH Policy....................................................................... 179 8.3.3. Mental health policy ................................................................................................................ 182 8.3.4. Application of theory .............................................................................................................. 183 8.4. Summary .......................................................................................................................................... 190 Chapter 9 ......................................................................................................................... 191 Impacts of occupational stress & burnout on clinical officers and health outcomes 191 9.1. Introduction ............................................................................................................................................ 191 9.2. Impact of occupational stress and burnout ........................................................................................ 191 9.2.1. Psychological consequences........................................................................................................ 192 9.2.2. Social Consequences .................................................................................................................... 197 9.2.3. Physical consequences ................................................................................................................. 199 9.2.4. Economic consequences .............................................................................................................. 200 9.3. Discussion ....................................................................................................................................... 201 9.3.1. Poor quality of life ................................................................................................................... 201 v 9.3.2. Job disengagement ................................................................................................................ 202 9.3.3. Cholera outbreak amidst COVID-19 pandemic ..................................................................... 205 9.4. Impact shifting to the general public ............................................................................................. 207 9.4.1. Patient Satisfaction ................................................................................................................. 207 9.4.2. Application of the fundamental cause theory ...................................................................... 215 9.5. Summary .......................................................................................................................................... 220 Chapter 10 ....................................................................................................................... 221 Conclusion and Recommendations .............................................................................. 221 10.1. Introduction .......................................................................................................................................... 221 10.2. Policy interventions ............................................................................................................................. 221 10.2.1. Task shifting ................................................................................................................................. 221 10.2.2. Other policy interventions ........................................................................................................... 223 10.3. Impact shifting ..................................................................................................................................... 224 10.4. Study limitations .................................................................................................................................. 226 10.5. Recommendations ............................................................................................................................... 227 10.5.1. Research level .............................................................................................................................. 228 10.5.2. Policy level .................................................................................................................................... 228 10.5.3. Practical level ............................................................................................................................... 229 10.6. Summary .............................................................................................................................................. 230 Appendix 1: Guide for a semi-structured interview ..................................................................................... 232 Appendix 2: Guide for focus group discussion ........................................................................................... 233 Appendix 3: Participant Information Sheet ................................................................................................. 234 Appendix 4: Informed Consent Form .......................................................................................................... 237 References .................................................................................................................................................... 238 Declaration I declare that this is my unaided work submitted to the Faculty of Humanities, University of the Witwatersrand for the Doctor of Philosophy degree (Sociology). It has not been submitted before for examination in any other university. Signed 10 August 2023 vii Abstract In Malawi, there is a cadre of mid-level health workers called clinical officers who undertake duties conventionally designated for medical doctors in the wake of an acute shortage of the latter. The use of clinical officers as substitutes for medical doctors is one example of a strategy called task shifting that is implemented as a temporary remedy for the shortage of human resources in healthcare. This is a study on the experiences of clinical officers with occupational stress and burnout at public hospitals in Malawi. The study adopted a qualitative research design with a case study as a research strategy. The study was conducted at four district hospitals and one central hospital, all of which are state-owned. One shortcoming of the framing of occupational safety and health in Malawi is the narrow scope and coverage of the regulation on occupational safety and health. This narrow scope of the regulation of occupational safety and health is limited to physical, chemical, and biological hazards. The psychosocial hazards are therefore neglected by the regulation on occupational safety and health. Another shortcoming of the framing of occupational safety and health in Malawi is that the coverage of the regulation on occupational safety and health exempts service sectors like healthcare. This exemption, therefore, gives the impression that healthcare in Malawi is immune to occupational safety and health hazards. This study challenges the narrow scope and coverage of the regulation on occupational safety and health in Malawi that neglects psychosocial hazards and exempts healthcare. The overall aim of the study was to expose the impacts on public health that can be associated with the neglect of psychosocial hazards and the exclusion of healthcare from the regulation of occupational safety and health. This study demonstrates that there are psychosocial hazards at public hospitals that predispose clinical officers to occupational stress and burnout. These are excessive workload, long hours of work, poor interprofessional relations, restructuring, COVID-19 responses, and the absence of occupational and safety management systems. The study further illustrates that psychosocial hazards at public hospitals are a breeding ground for various health problems among clinical officers that emanate from occupational stress and burnout. viii These health problems include emotional and cognitive effects; injuries; high blood pressure (hypertension); muscle tension or pain; and severe headaches. These health problems negatively affect the quality of life among clinical officers and their performance on the job. The study, therefore, concludes that occupational stress and burnout among clinical officers ultimately affect health outcomes in the broader population. For instance, the study demonstrates how the consequences of OS and burnout among clinical officers are consequently externalised to patients and the general public through the poor quality of healthcare services. In this study, the externalisation of the negative effects of occupational stress and burnout on clinical officers to the patients and the general public, is referred to as impact shifting. This study conceptualises and proposes a theoretical framework for analysing occupational safety and health in Malawi, with a particular focus on psychosocial hazards at public hospitals. The theoretical framework comprises three theoretical perspectives, namely: attribution theory, job demands-resources model, and fundamental cause theory. This study, therefore, offers a theoretical foundation and empirical evidence drawn from the experiences of clinical officers with occupational stress and burnout. The theoretical foundation and empirical evidence can inform the reframing of the scope and coverage of the regulation on occupational safety and health. Finally, this study also conceptualises and proposes a framework for the formulation of a comprehensive policy on occupational safety and health for public health facilities in the context of Malawi. Keywords: clinical officers; occupational stress; burnout; occupational safety and health; psychosocial hazards; public hospitals, Malawi. Dedication Those who have physically departed, to whom I invariably pay homage as my African ancestors at the family, community, national and racial levels. Never did I cease to feel their spiritual presence throughout this arduous PhD journey; Those who have contributed various efforts to the struggle for the emancipation of the exploited, downtrodden, and marginalised; My three sons: Alinafe, Kondwani, and Chifunilo, please consider this an inspiration in your academic endeavours! Acknowledgements This doctoral (PhD) project was first conceived in 2017 following spectacular sheds of inspiration from two distinguished academics who served as mentors to me, namely: Prof. Musa Dube (University of Botswana) and Prof. Trywell Kalusopa (University of Namibia). From the beginning to the end of my doctoral work, I received academic supervision (both formally and informally) from a variety of scholars, for which I am grateful. These are Prof. Bridget Kenny, Dr Ben Scully, and the late Dr Rajohane Matshiditsho (University of Witwatersrand); Dr Kaelo Molefhe and Dr Thekiso Molokwane (University of Botswana); Dr Bernadette O’Hare (St. Andrews University); and Prof. Adamson Muula (Kamuzu University of Health Sciences). I should also make mention of other scholars who provided valuable ideas towards my doctoral work, to whom I am also thankful: 1. Three examiners of my doctoral thesis i.e., Prof. Alexandar Gallas (Kassel University), Prof. Siphelo Ngcwangu (University of Johannesburg) and Dr. Kezia Lewins (Wits University); 2. Two readers of my doctoral proposal i.e., Dr D. Moyo and Dr. T. Sefalafala (Wits University); 3. Head of Department, lecturers and postgraduate students in the Sociology Department (Wits University) who participated in the departmental seminar held on 22 October 2020 during which I presented my doctoral proposal. I am also grateful to the five individuals who provided their services as research assistants. These are: Yobe Saka, Matsiame Mafa, Emmanuel Katema, Anna Kazembe, and Chifuno Mlambe. I also acknowledge the valuable advice at a technical level that I consistently sought from a health researcher in Malawi called Peter Makaula. I am appreciative of the financial assistance I received from LO/Norge, Rutgers University’s Center for Global Work and Employment (CGWE) and the Board of African Studies as well as the technical and moral support from the Physician Assistants Union of Malawi (PAUM) and Lost History Foundation (LHF), without which it would have been difficult for me to conduct the study smoothly and complete it as I did. I am also grateful to the respondents for agreeing to take part in my study and for providing the valuable data that I requested. More importantly, I thank the management of Queen Elizabeth Central Hospital, Chikwawa District Hospital, Mulanje District Hospital, Balaka District Hospital, and Nkhatabay District Hospital for responding promptly and positively to my request to conduct a study at their respective hospitals. Finally, I must mention that I have been assisted by many persons and institutions in conceptualising doctoral research, fetching relevant literature, organising the ethics applications, gathering data, IT services, tips, stationery, logistics, fund raising among others. Such assistance came in various forms, like voluntary service, material and financial support, and otherwise. For reasons of space, I cannot give a detailed acknowledgement in this regard. To all those whose names are not mentioned on this page, I offer my sincere apologies. I hope they will understand that I am nonetheless grateful to them for their assistance towards my doctoral work. List of abbreviations & acronyms BHP Basic Health Package BHP+ Basic Health Package Plus BSc Bachelor of Science CHAM Christian Health Association of Malawi CO Clinical Officers CoTU COVID-19 Treatment Unit DHMT District Health Management Team EHP Essential Health Package EHRP Emergency Human Resources Programme GNT Government Negotiating Team HRHC Human Resources for Health Coalition IFIs International Financial Institutions ILO International Labour Organisation IMF International Monetary Fund IPCP Interprofessional Collaborative Practice JD-R Job Demands-Resources LICs Low Income Countries NGOs Non-Governmental Organisations NONM National Organisation of Nurses and midwives of Malawi OS Occupational Stress PAUM Physician Assistants Union of Malawi PCR Polymerase Chain Reaction PPE Personal Protective Equipment SAPs Structural Adjustment Programmes SPSS Statistical Package for Social Sciences TB Tuberculosis ToRs Terms of References UCAHP Union for Clinicians and Allied Health Professionals URL Uniform Resource Locators WHO World Health Organisation xii List of Figures Page Figure 1-1: Conceptual framework of burnout ....................................................................................... 2 Figure 2-1: Key findings ............................................................................................................................ 7 Figure 3-2: Administrative map of Malawi ............................................................................................ 20 Figure 4-3: Evolution of occupational safety & health in Europe and North America .................... 35 Figure 5-3: Evolution of occupational safety & health in Malawi ....................................................... 38 Figure 6-3: Ratified ILO conventions on occupational safety & health ............................................ 39 Figure 7-3: Framework for a risk assessment on psychosocial hazards ......................................... 53 Figure 8-3: Theoretical framework on occupational safety & health ................................................ 59 Figure 9-4: Gantt chart for data collection and analysis ..................................................................... 75 Figure 10-4: Trustworthiness & authenticity ......................................................................................... 89 Figure 11-5: Sources of occupational stress & burnout before the COVID-19 pandemic ............ 93 Figure 12-6: Three forms of restructuring in the health sector ........................................................ 118 Figure 13-6: Structure of a district council .......................................................................................... 119 Figure 14-6: Prof. Felix Salaniponi graduated from the second cohort of locally trained clinical officers ...................................................................................................................................................... 121 Figure 15-6: License for practice as a clinical officer issued to a diploma holder ........................ 128 Figure 16-6: How restructuring negatively affects occupational stress and burnout ................... 142 Figure 17-7: Amendments to Corona virus prevention, containment and management rules by November 2021. ..................................................................................................................................... 147 Figure 18-7: Daily confirmed new COVID-19 cases & deaths per million people during 1st & 2nd waves ....................................................................................................................................................... 155 Figure 19-7: Outside the COVID-19 Treatment Unit, Kamuzu Central Hospital on 18 Jan 2021. .................................................................................................................................................................. 157 Figure 20-7: Daily confirmed new COVID-19 cases & deaths per million people (Nov 2021-April 2022). ....................................................................................................................................................... 161 Figure 21-8: Elements of OSH management system ....................................................................... 174 Figure 22-8: Proposed elements of a comprehensive OSH policy ................................................. 182 Figure 23-8: Conceptual framework on job demands among clinical officers .............................. 189 Figure 24-9: Impact of occupational stress & burnout on clinical officers. .................................... 192 Figure 25-9: Job disengagement causing stress and burnout on fellow clinical officers ............ 203 Figure 26-9: Inside a Cholera Treatment Unit in Blantyre ............................................................... 206 Figure 27-9: Conceptual framework on occupational stress & burnout and patient satisfaction208 List of tables Page Table 1-2: Regions and districts of Malawi .......................................................................................... 19 Table 2-2: Profiles of 5 districts where study sites are located ......................................................... 22 Table 3-2: Organisations of health workers in Malawi ........................................................................ 28 Table 4-3: Occupational accidents reported in Malawi (2015-2020). ............................................... 55 Table 5-3: Attributions for occupational accidents, injuries & diseases by workers and managers .................................................................................................................................................................... 62 Table 6-4: Sample size ............................................................................................................................ 76 Table 7-5: Vacancy rates for clinical officers at the 5 public hospitals ............................................. 94 Table 8-6: Increase of health professionals in public & CHAM facilities (2004-2009) ................. 123 Table 9-9 Types of medical errors and mistakes .............................................................................. 195 1 Chapter 1 Introduction 1.1. Background As a trade union activist, one shortcoming I discovered in the framing of occupational safety and health (OSH) in Malawi is the narrow scope and coverage of OSH regulation. This narrow scope of OSH regulation is confined to physical, chemical, and biological hazards. As a result, OSH regulation in Malawi neglects psychosocial hazards. However, in other parts of the world like Europe and North America, the framing of OSH evolved from such a narrow scope to incorporate psychosocial hazards (Eddington, 2006; European Commission, 2011; Väänänen et al., 2012). Another shortcoming of the framing of OSH in Malawi that I also discovered is that the coverage of OSH regulation exempts service sectors like healthcare. This exemption, therefore, gives the impression that healthcare in Malawi is immune to OSH hazards. In this doctoral (PhD) research, I challenge the narrow scope and coverage of OSH regulation in Malawi that neglects psychosocial hazards and exempts healthcare. Using the experiences of clinical officers (COs) at Malawi’s public hospitals, I build a case that occupational stress (OS) is a serious public health problem such that psychosocial hazards should become integral to OSH regulation. Drawing from Tan (1991), psychosocial hazards are aspects of the design and management of the work that may exacerbate the risk of work-related stress or contribute to psychological and physical harm. OS refers to “harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker” (National Institute for Occupational Safety and Health, 1999, p. 2). The European Agency for Safety and Health at Work (2009, p. 14) substantiated that “work-related stress is experienced when the demands of the work environment exceed the workers’ ability to cope with (or control) them.” According to Mijakoski et al. (2015), burnout is characterised by a sustained OS among health workers. The authors further explain that, among others, burnout manifests itself through extreme feelings of exhaustion, frustration, anger, and cynicism, as well as ineffectiveness and failure. 2 Maslach and Jackson (1981) and Maslach et al. (1997) elaborated that burnout is characterised by three main categories of symptoms namely: emotional exhaustion, depersonalization, and reduced personal accomplishment as shown in Figure 1-1 (below). Figure 1-1: Conceptual framework of burnout Adapted from Maslach and Jackson (1981) and Maslach et al. (1997) Emotional exhaustion is a “state of feeling emotionally worn-out and drained as a result of accumulated stress from your personal or work life, or a combination of both” (Fan et al., 2023, p. 2). Those who experience emotional exhaustion tend to feel helpless and out of control (Maslach & Jackson, 1981; Maslach et al., 1997). Such feelings of disconnectedness or detachment from one's body, thoughts or environment is what other scholars refer to as depersonalization (Phillips et al., 2001). Reduced personal accomplishment is a propensity for individuals to appraise themselves poorly and a pervasive sense that they are no longer performing relevant and vital tasks (Skaalvik & Skaalvik, 2009). At the workplace, depersonalization involves doubting the value of one’s tasks or duties. Emotional exhaustion, depersonalization, and reduced personal accomplishment can be manifested through disruptions or breakdowns of memory, consciousness, awareness, concentration, identity, perception, and feelings of frustration, anger, depression, and resentment among others (Maslach & Jackson, 1981; Maslach et al., 1997; Skaalvik & Skaalvik, 2009; Phillips et al., 2001; Fan et al., 2023). These symptoms can ultimately interfere with an individual’s general functioning in all sphere of life including personal life and work activities (Maslach & Jackson, 1981; Maslach et al., 1997; Skaalvik & Skaalvik, 2009; Phillips et al., 2001; Fan et al., 2023). Throughout this 3 thesis, I refer to emotional exhaustion, depersonalisation and reduced personal accomplishment as forms of OS and burnout. 1.2. Problem statement Wherever healthcare is practiced, OSH hazards are inevitable (Gestal, 1987). Among the OSH hazards associated with healthcare are those that cause or exacerbate OS and burnout, which are particularly referred to as psychosocial hazards (d'Ettorre & Greco, 2015; Salilih & Abajobir, 2014). Orji et al. (2002) highlighted a hospital staff paradox. The authors argued that while the hospital staff is primarily responsible for taking care of the health of others, sometimes the hospital staff neglects itself, and in other instances, it is neglected by policymakers when it comes to OSH. For instance, a law that regulates OSH in Malawi is called the Occupational Safety, Health, and Welfare Act of 1997 (Malawi Government, 1997). Malawi also has a national programme on OSH that is derived from the Act (Malawi Government, 2012). The scope and coverage of the OSH Act and OSH national programme neglect psychosocial hazards and further exempt service sectors like health care. As such, OSH hazards and incidents like accidents, injuries, stress, and other occupational illnesses at health facilities are not monitored, assessed, or reported by the state through the Ministry of Labour (Malawi Government, 2018b). However, the reality is that health workers in Malawi are susceptible to OSH hazards like workers in other sectors that are covered by OSH regulation, i.e., construction and manufacturing. In Malawi, the psychosocial hazards among health workers are partly associated with donor support. Besides domestic revenues, the health sector in Malawi is also financed by funds from international donors (Borghi et al., 2018; Malawi Government, 2017a, 2018b). The funds from international donors, which constitute 80 per cent of total expenditure on health, are targeted at treating various illnesses (Kim et al., 2019). “The disease-specific donor funding often neglects the basic primary health care systems and human resources that are the essential foundation required to achieve optimal health outcomes” (Kim et al., 2019, p. 9). As such, the number of health workers on the government payroll continues to be insufficient in the health sector (Bradley et al., 2015; Mangham, 2007; Palmer, 2006). To overcome the severe lack of health professionals, various fundamental changes in working arrangements have been implemented at public hospitals in Malawi (Bradley & McAuliffe, 2009; Mangham, 4 2007). These fundamental changes include increased workloads, longer hours of work (beyond the regular eight-hour shift), limiting of "off-duty" time, more frequent night shifts, multi-tasking with little or no supervision, and required support (Bradley & McAuliffe, 2009; Mangham, 2007). As I demonstrate in Chapter 7, the emergence of COVID-19 pandemic, intensified the fundamental changes at the public hospitals in terms of excessive workloads and longer hours of work among clinical officers (COs). As health workers in Malawi strive to cope with the fundamental changes at the workplace, they encounter OS and burnout (Gondwe & Brysiewicz, 2008). Given the high population coupled with rising pressure on health systems, Malawi has the world’s second-lowest number of medical doctors per capita, such that there is an insufficient number of medical doctors at public hospitals (Dovlo, 2004; Gajewski et al., 2019). In response to the critical shortage of qualified medical doctors, in 1976, the Ministry of Health introduced a mid-level cadre of health workers called COs to undertake duties conventionally performed by medical doctors (Bradley & McAuliffe, 2009; Chilopora et al., 2007; Gajewski et al., 2019; Grimes et al., 2014; Jiskoot, 2008; Mkandawire et al., 2008). Though the COs are employed as substitutes for qualified doctors, the period of training for COs is shorter than that for medical doctors, i.e., 4 years and 7 years, respectively (Bradley & McAuliffe, 2009; Chilopora et al., 2007; Gajewski et al., 2019; Grimes et al., 2014; Jiskoot, 2008; Mkandawire et al., 2008). Upon “completion of the training, COs face a difficult job: they must work as medical doctors in the hospitals, but they lack sufficient knowledge and skills” (Jiskoot, 2008, p. 74). For instance, COs are provided with fewer and less expensive diagnostic tests and equipment for their work (Dovlo, 2004). Furthermore, COs also do not receive recognition, respect, and necessary support from doctors and health administrators (McAuliffe, Manafa, et al., 2009). “Recent research indicates that these cadres are becoming demotivated due to poor career development and promotion prospects and a lack of positive supervision, feedback, and recognition, which leave them feeling unsupported and undervalued” (McAuliffe, Manafa, et al., 2009, p. 81). Subsequently, there have emerged tensions, frustrations, and conflicts between COs on the one hand and medical doctors on the other (Bradley & McAuliffe, 2009; McAuliffe, Bowie, et al., 2009). Such tensions, frustrations, and interprofessional conflicts provide fertile grounds for poor psychosocial welfare among 5 health workers (Bendix, 2019; Töyry, 2005). In the context of Malawi, tensions, frustrations, and inter-professional conflicts between COs and medical doctors (Bradley & McAuliffe, 2009; McAuliffe, Bowie, et al., 2009) may pose a predisposition to mental illnesses among COs such as OS and burnout. The problem of my study is therefore the narrow scope and coverage of OSH regulation in Malawi, which neglects psychosocial hazards and excludes healthcare. 1.2.1. Aim of the study I embarked on this study to expose the impacts on public health that can be associated with the neglect of psychosocial hazards and the exclusion of healthcare from the regulation of OSH. 1.2.1.1. Research questions The central research question for my study was: ➢ Are clinical officers (COs) at public hospitals in Malawi predisposed to occupational stress (OS) and burnout? In particular, I examined the following four sub-research questions: 1. What are the sources of occupational stress (OS) and burnout among clinical officers (COs) at Malawi’s public hospitals? 2. Are there workplace policies that address occupational stress (OS) and burnout among clinical officers (COs) at Malawi’s public hospitals? 3. How did the COVID-19 pandemic contribute to occupational stress (OS) and burnout among clinical officers (COs) at Malawi’s public hospitals? 4. Are there consequences of occupational stress (OS) and burnout among clinical officers (COs) at Malawi’s public hospitals? 1.2.1.2. Overview of findings The narrow scope and coverage of OSH regulation that neglects psychosocial hazards and exempts services like healthcare pose several assumptions. In this thesis, I demonstrate that these assumptions are harmful to health workers in general and COs in particular. Among others, the narrow scope and coverage of OSH regulation that neglects psychosocial hazards and exempts services like healthcare give the impression that: 1. Psychosocial hazards do not exist at the workplaces in Malawi; 6 2. If at all psychosocial hazards do exist at the workplace, they do not pose a critical problem that would warrant policy intervention at both the workplace and national levels; 3. Hospitals as spaces through which healthcare services are delivered are immune to OSH hazards, hence the exemption of healthcare in OSH regulation. In this thesis, I challenge these three implicit assumptions using empirical evidence drawn from the practical experiences of the COs at public hospitals with OS and burnout. In particular, I challenge the implicit assumptions by first demonstrating that there are psychosocial hazards at public hospitals that predispose COs to OS and burnout. I argue that contrary to three implicit assumptions posed by the narrow scope and coverage of OSH regulation that neglects psychosocial hazards and exempts services like health care, there is a myriad of psychosocial hazards at public hospitals. As shown in Figure 2-1 (below), the findings of my study show that psychosocial hazards at public hospitals include excessive workload, long hours of work, poor interprofessional relations, restructuring, COVID-19 responses, and the absence of OSH management systems. I divide these psychosocial hazards into two categories. The first category consists of psychosocial hazards from the confines of the workplace: excessive workload, long hours of work, poor interprofessional relations, and the absence of OSH management systems. The psychosocial hazards from outside the workplace, such as restructuring and COVID-19 responses, fall in the second category. Furthermore, in this thesis my focus is two fold. Firstly, I illustrate how psychosocial hazards (shown in Figure 2-1) cause and aggravate OS and burnout among COs at public hospitals. Within this first fold, I argue that before and during the COVID-19 pandemic, there was a combination of psychosocial hazards (shown in Figure 2-1) that caused and increased the risks of OS and burnout among COs at public hospitals. Secondly, I demonstrate how OS and burnout among COs contribute to psychological, social, physical, and economic consequences, as highlighted in Figure 2-1 (below). 7 Figure 2-1: Key findings In the second fold, I articulate two key arguments. Firstly, I argue that psychosocial hazards at public hospitals as shown in Figure 2-1 (above), are a breeding ground for various health problems that emanate from OS and burnout among COs. Among others, these health problems are manifested through the psychological and physical consequences of OS and burnout as shown in Figure 2-1. Secondly, I argue that the consequences of OS and burnout among COs ultimately affect health outcomes in the wider population. Hence, there is an externalisation of the negative effects of occupational stress and burnout among COs to the patients and general public, which I refer to as impact shifting. 1.3. Rationale for choice of a country and subjects Besides that it would be far much convenient in terms of cost and access for me to conduct the PhD research in Malawi which is my home country, there was another reason that compelled me to choose Malawi. Malawi is one of the low-income countries (LICs) which are confronted by the world's most pronounced crisis as far as the human resources for health are concerned (Callaghan et al., 2010; Lehmann et al., 2009; Okyere et al., 2017; Sabet Sarvestani et al., 2021). Against this backdrop, task shifting is practiced as a solution to address the limited available human resources for the delivery of healthcare services in LICs such as Malawi (Okyere et al., 2017; Sabet Sarvestani et al., 2021). Task shifting is defined as “a strategy where non-qualified (or less qualified) health workers are given responsibilities normally performed by highly qualified and highly skilled health professionals” (Muula, 2016, p. 26). For instance, in Malawi, Mozambique and Tanzania, 90 per cent of complex tasks conventionally performed by physicians such as emergency obstetric operations, are delegated to non-physician and mid-level health workers (Okyere et al., 2017). In my PhD research, Malawi represents LICs that are implementing task shifting as one 8 strategy of delegating specific tasks conventionally designated for medical doctors to mid-level health workers who are less specialised such as COs. Lastly, while tasking shifting is accepted as a viable response to the acute shortage of human resources for health (Okyere et al., 2017; Sabet Sarvestani et al., 2021), there are growing debates on the expediency, efficacy and modalities of task shifting in LICs (Lehmann et al., 2009). In an effort to contribute to the broader debates on expediency, efficacy and modalities of task shifting, I selected COs to constitute an ideal case study on task shifting within the confines of OSH. 1.4. Overview of the methodology This study adopted a qualitative explanatory research design with a case study as a research strategy. The research was conducted at the following five district hospitals and one central hospital, all of which are state-owned: Mulanje District Hospital, Chikwawa District Hospital, Balaka District Hospital, Nkhatabay District Hospital, and Queen Elizabeth Central Hospital in Blantyre. I discovered that there were approximately 152 COs employed at these four district hospitals and 1 central hospital. Out of 152 COs, I recruited 25 (5 at each hospital) to participate in the study. Three methods of qualitative data collection were used, namely: semi-structured interviews, focus group discussions, and document analysis. I developed the doctoral research proposal and ethics clearance applications during the COVID-19 pandemic. Both the proposal and ethics clearance applications were approved amidst the pandemic. Due to the COVID-19 protocols imposed by the university ethics committees, I was compelled to conduct the semi-structured interviews and focus group discussions virtually. In addition to the 5 COs from different departments at each of the five district hospitals, 1 immediate COs’ supervisor from each hospital was selected for the semi-structured interviews. Finally, six semi-structured interviews were also conducted with six key informants outside the public hospitals, as follows: 1. Policy specialist at Ministry of Health (1); 2. An official from the Medical Council of Malawi (1); 3. An official from a trade union representing COs (1); 4. Occupational health physician (1) 5. Retired COs (2). 9 In total, 36 semi-structured interviews were conducted with COs at the five public hospitals and key informants outside the public hospitals. In addition, at each of the five public hospitals, one focus group discussion was held with 4-5 COs representing various departments or units. In total, five focus group discussions were conducted with COs. The five hospitals were chosen as study sites using convenience sampling based on the hospital's conditions for granting study permissions. However, at each hospital, I used purposive sampling to recruit the COs, immediate supervisors for COs, and key informants as respondents. A method of data analysis called thematic analysis was adopted. This method involved the transcription of the virtual interviews and focus group discussions that had been recorded. A computer programme called Atlas. ti version 9 was used to conduct thematic analysis on the transcriptions as well as the relevant documents that were gathered. These documents included statements, reports, and memos by the Physician Assistants Union of Malawi (PAUM); policy documents, reports, and statements issued by the Ministry of Health; and reports, memos, and charts by the hospital administration. The thematic analysis of the transcriptions and documents involved creating codes, revising the codes, identifying recurring themes, and merging the themes where necessary (Maguire & Delahunt, 2017). Informed consent and voluntary participation were mandatory for every respondent. Since data collection was conducted virtually, informed consent was obtained orally and captured in the audio recording before the commencement of an interview or focus group discussion. The study was approved by the Human Research Ethics Committee (Medical) of the University of the Witwatersrand and the Committee on Research Ethics in the Social Sciences and Humanities at the National Commission for Science and Technology in Malawi. 1.5. Significance of the study The importance of this study can be demonstrated on two fronts: theoretical and practical/policy. One weakness I identified with the literature on OSH for mid-level health workers in Malawi is a lack of theoretical analysis. As I demonstrate in Chapter 3 (a literature review), the articles on OSH among mid-level health workers (including those targeting COs) that I reviewed, are devoid of a theoretical lens. I argue that scholarly literature on aspects of OSH without an analysis grounded in theory, is 10 intellectually inadequate. Various theories should be drawn in scholarly work to enrich an understanding of workplace safety and health (DeHury & Kumar, 2019). There are practical implications for the lack of theoretical perspectives when discussing OSH among health workers in Malawi. The lack of a theoretical lens entails insufficient scientific knowledge of OSH conditions that would appropriately inform the formulation and implementation of the workplace and national policies towards the effective delivery of healthcare services (World Health Organization, 2007a). For instance, there is an acknowledgement by the Ministry of Health that “in the health sector (Malawi), essential safety measures and workforce protection policies are often overlooked” (Malawi Government, 2018b, p. 85). This might reflect a paucity of research grounded in the theory that should have illuminated the actual situation of OSH in the health sector and the practical OSH interventions that are required. I attempted to address the intrinsic deficiency in the theoretical analysis as far as research on OSH for health workers in Malawi is concerned, by exploring different social theories. In this thesis, I propose a theoretical framework for analysing OSH in Malawi with a particular focus on psychosocial hazards at public hospitals, both of which are neglected and exempt from OSH regulation. As I discuss in greater detail in Chapter 3 (literature review), the theoretical framework that I propose is made up of three theoretical perspectives: attribution theory, the job demands-resources (JD-R) model, and the fundamental cause theory. In Chapter 3, I establish that attribution theory as advanced by Gyekye (2010), is narrowly confined to OSH hazards for which employers have a primary responsibility to intervene. Hence, Gyekye (2010) did not go beyond the workplace environment in his analysis of attributions for occupational accidents, injuries and diseases. Using empirical evidence from COs' practical experiences with OS and burnout, I show in this thesis that it is possible for employees and managers to attribute factors from outside of the work environment when making causal explanations of OS and burnout. Hence, in this thesis, I apply attribution theory beyond the confines of the workplace. Drawing from Gyekye (2010), in Chapter 3 I discuss biases and errors in light of attribution theory. From the literature, I highlight five attribution biases and errors: fundamental attribution error, optimism bias, self-serving bias, false consensus effect, 11 and actor-observer bias, as conceptualised by Ross (1977), Caponecchia (2010), Shepperd et al. (2008), Mullen et al. (1985), and Malle (2006), respectively. Having established that it is possible to attribute OS and burnout to factors beyond the workplace, I add that it is also possible to commit the error or bias of ignoring factors beyond the workplace. I coin this attribution error or bias as work environment bias, which I have defined in Chapter 8. Hence my significant contribution to scholarship at the theoretical level is the generation of evidence that allows me to broaden the application of attribution theory beyond the workplace, then coin and add the work environment bias to the list of attribution biases and errors. In Chapter 3, I further discuss that the JD-R model offers a broad scope and flexibility such that it applies to different work settings (Schaufeli & Taris, 2014). Hence, my other significant contribution to scholarship at a theoretical level is the flexibility that I exercise to apply the JD-R model to a hospital setting in Malawi. As I elaborate in chapters 8–11, I identified specific job demands and job resources at public hospitals in Malawi that interact to influence OS and burnout among COs. While the studies on OSH among mid-level health workers in Malawi I reviewed in Chapter 3 shed light on the impact of OS and burnout on the quality of healthcare, they do not illustrate how OS and burnout affect the quality of healthcare services. Neither do these studies shed light on the impact of OS and burnout on the health well-being of the mid-level health workers themselves, as illustrated by the global literature, i.e., gastric complaints, nervous disturbances, chronic fatigue, headaches, sleep disorders, breast cancer, stroke, and increased consumption of tranquillizers and sleeping tablets (Lin et al., 2014; Pikó, 1999; Rivera et al., 2020; Wichert, 2002). In Chapter 9, I provide empirical evidence to illustrate the impact of OS and burnout on the quality of life of the COs themselves. In Chapter 9, I also provide empirical evidence to demonstrate how OS and burnout among COs negatively affect the quality of healthcare services at public hospitals and ultimately health outcomes. Against this backdrop, I develop a concept that I call impact shifting. I use this concept in Chapter 9 to argue that the consequences of OS and burnout are not confined to individual COs. I demonstrate in Chapter 9 that the negative effects of OS and burnout among COs are consequently externalised to the general public through the poor quality of health services rendered by COs. 12 The second front of significance for my study lies on the practical and policy levels for three reasons. Firstly, Eddington (2006) argued that it is unethical for a society to ignore OSH hazards among health workers and continue to exploit them while inflicting injuries, illnesses, trauma, pain, and possibly death on them. Hence, the narrow scope and coverage of OSH regulation in Malawi that neglects psychosocial hazards and exempts services such as health care should be considered unethical. On a positive note, there are drafting and consultation processes on OSH policy instruments currently underway in Malawi. For instance, there are drafting processes to develop a Bill of Parliament on occupational health services called the Occupational Health Centre Act of 2023. The aim of the Bill is to ensure the availability of high-quality occupational health services in the country. The Bill proposes the following: 1. establishment of an Occupational Health Center as a tertiary-level facility for the diagnosis and management of occupational diseases; 2. legal framework for the sustainability of occupational health services by implementing the requirement for employers to cover costs for occupational medical examinations; 3. model for the management of an Occupational Health Center as a cost recovery institution with the potential to make profits in the foreseeable future through the fees collected from the services provided. As stipulated by the Malawi Government (2011a) and Malawi Government (2020a), national consultation processes are also being conducted on the drafting of a national OSH policy, a national OSH action plan, and a national OSH information and documentation system. Furthermore, the OSH Act of 1997, the national programme on OSH (2011–2016), and the OSH profile (2009) are currently under review (Malawi Government, 2020a). These drafting and consultation processes on the above- mentioned OSH policy instruments1 can be considered critical developments in the evolution of OSH in Malawi. There is room, in the wake of ongoing drafting and consultation processes on OSH policy instruments, to expand the scope and coverage of OSH regulation along two postulations drawn from this doctoral thesis: 1. Expanding the scope of OSH regulation to incorporate psychosocial hazards; 1 The consultations and drafting processes on these OSH policy instruments, were still underway at the time I finally submitted this thesis to the university. 13 2. Extending the coverage of OSH regulation to incorporate healthcare as a sector that is also prone to OSH hazards like other sectors. Hence, my study comes at a critical juncture to offer a theoretical foundation and empirical evidence drawn from COs’ practical experiences on OS and burnout to inform the reframing of OSH towards achieving the two goals highlighted above. The second reason for the significance of my study at the practical and policy levels relates to the non-existence of OSH policy at public hospitals. I discovered that there was no comprehensive OSH policy at the public hospitals that guided hospitals to eliminate or minimise risks to health and safety. Against this backdrop, my significant contribution at both the policy and practical levels is the conceptualization of a framework for a comprehensive OSH policy for public hospitals (Chapter 8). This framework proposes that a comprehensive OSH policy for public hospitals should be aimed at protecting the safety and health of the hospital staff by preventing injuries, ill health, diseases, and incidents related to various categories of OSH hazards in compliance with OSH statutes and ILO conventions on OSH ratified by the Malawi Government. The framework further recommends that, among others, a comprehensive OSH policy should make provisions for regularly conducting OSH risk assessments, providing adequate resources for implementing OSH policy and providing regular training on OSH targeting all hospital staff. The third reason for the significance of my study at the practical and policy levels relates to paucity of studies on OSH in least developing countries such as Malawi. Despite the increasing interest in OSH, studies on OSH particularly those that target health workers in least developing countries are scarce (Tait et al., 2018). According to Rantanen et al. (2004), only 5 per cent of research on OSH is conducted in the least developing countries, despite that this is where 80 per cent of the world's working population is found. Against this backdrop, OSH regulatory frameworks in the least developing countries, often rely on research from developed countries that may not be applicable to the local contexts in the least developing countries (London & Kisting, 2017). There are practical implications of little or no research on OSH particularly targeting health workers in developing countries like Malawi. Little or no research entails insufficient scientific knowledge of OSH conditions that would appropriately inform the 14 formulation and implementation of workplace and national policies towards the effective delivery of healthcare services (World Health Organization, 2007). For instance, there is an acknowledgement that “in the health sector (Malawi), essential safety measures and workforce protection policies are often overlooked” (Malawi Government, 2018, p. 85). This is typically a reflection of paucity of research on OSH that should shed light on the actual situation of OSH in the health sector and appropriate OSH interventions that are required. 1.6. Location and structure of the thesis The broader topic of my doctoral study is OSH. OSH encompasses a wide range of disciplines such as medicine, physics, chemistry, engineering, economics, law, sociology, public administration among others (Alli, 2008). In this thesis, I analyse the conditions and dimensions of work performed by the COs in a hospital setting as far as OS and burnout are concerned. As shown in Figure 2-1 (above), I particularly examine the relations between COs and medical doctors and the influence of other phenomena like restructuring and the COVID-19 pandemic on the work, leisure, health and well-being of the COs. In this thesis, I also articulate how health problems emanating from OS and burnout among COs ultimately influence the health in the wider population. Against this backdrop, I place this thesis in two sub-fields of sociology namely: sociology of health and sociology of work. I have organised this thesis into 10 chapters as follows: Chapter 1- Introduction In this chapter, I introduce the key components of the study. I define OS and burnout, highlight the problem statement, aim of the study, research questions, summary of findings, an overview of the methodology, the significance of the study, and how the thesis is organised. Chapter 2- Setting the context In this chapter, I present background information about Malawi. This background information provides a broader context within which the study was conducted, such as the socio-economic and administrative contexts of Malawi. Finally, I highlight the architecture of healthcare service delivery to illustrate the location of COs in the provision of healthcare services in Malawi. 15 Chapter 3- Literature review In this chapter, I present a review of the literature on OSH. I discuss the definition of OSH, how OSH has evolved in Europe and North America through three phases that culminated in the recognition of psychosocial hazards as integral to OSH theory and practice, sources and consequences of OS and burnout among health workers. I also illustrate the narrow scope and coverage of OSH regulation in Malawi, which neglects psychosocial hazards and excludes healthcare. I further review the literature related to OSH, focusing on mid-level health workers in Malawi (including COs). Finally, I discuss the theoretical framework that I have developed for the study. Chapter 4- Methodology In this chapter, I present the methodology that I used in the study. I discuss the research philosophy, research approach, and research strategy underpinning my study. I further demonstrate why a qualitative research design involving a combination of three methods of data collection—interviews, focus group discussions, and document analysis—was deemed appropriate for my study. I also discuss sampling procedures, reliability and validity, and how the data collected was organised and analysed. Finally, I highlight the ethical considerations that guided the conduct of my study. Chapter 5- Occupational stress and burnout at public hospitals before the COVID-19 pandemic In this chapter, I begin to challenge three implicit implications posed by the narrow scope and coverage of OSH regulation that neglects psychosocial hazards and exempts services like healthcare. I demonstrate that before the COVID-19 emerged, there were psychosocial hazards from the confines of the workplace that predisposed COs to OS and burnout. The psychosocial hazards I discuss in this chapter are excessive workloads, long hours of work, and poor interprofessional relations. Chapter 6- Restructuring in the health sector before the COVID-19 pandemic emerged In this chapter, I continue to challenge three implicit implications posed by the narrow scope and coverage of OSH regulation that neglects psychosocial hazards and exempts services like healthcare. I argue that before the COVID-19 pandemic emerged, restructuring was a psychosocial hazard from outside the workplace that 16 COs at public hospitals grappled with. I demonstrate that, among others, restructuring in the health sector manifested itself through the introduction of new processes on the job, new working procedures, new tasks, and revised organisational structures. Chapter 7- Occupational stress and burnout at public hospitals during the COVID-19 pandemic In this chapter, I continue to challenge three implicit implications posed by the narrow scope and coverage of OSH regulation that neglects psychosocial hazards and exempts services like healthcare. I argue that COVID-19 responses were psychosocial hazards from outside the workplace that predisposed health workers in general and COs in particular to OS and burnout. Among others, COVID-19 responses were manifested through the introduction of new processes on the job, new working procedures, and new tasks at public hospitals. Chapter 8- Policy and theoretical perspectives on occupational stress & burnout at public hospitals This chapter continues challenging the three implicit consequences of OSH regulation's narrow scope and coverage that neglects psychosocial hazards and exempts services such as healthcare. In this chapter, I demonstrate that at the five public hospitals, there were no organisational efforts to regularly identify OSH hazards. I contend that the lack of such organisational efforts indicates a poor safety culture in public hospitals. I draw a connection between poor safety culture at the policy level and OS or burnout among the COs. Finally, building on the discussions of chapters 5– 8, I use a theoretical lens to enrich the understanding of OS and burnout among the COs at public hospitals. Chapter 9- Impacts of occupational stress & burnout on clinical officers and health outcomes This chapter also continues challenging the three implicit consequences of OSH regulation's narrow scope and coverage that neglects psychosocial hazards and exempts services such as healthcare, In this chapter, I draw a connection between OS and burnout with the quality of life among COs. I postulate that OS and burnout among COs at public hospitals negatively affect the COs’ quality of life and job performance. I also demonstrate that the poor quality of healthcare services provided 17 by the COs leads to poor health among the masses. I further argue that psychosocial hazards at public hospitals are a breeding ground for health problems among COs through OS and burnout, which ultimately impinge the health of the wider population. Chapter 10- Conclusion and Recommendations In this chapter, I present the overall conclusion of the study drawn from the discussions in chapters 5–9. Thereafter, I highlight key recommendations at the research level derived from the limitations that I identified with my study. I also provide actionable recommendations at policy and practical levels for the consideration by the government, health workers (including the COs) and other stakeholders. 1.7. Summary In this chapter, I presented a definition of OS and then unpacked the concept of burnout. I also discussed the background, problem statement, aim of the study, a summary of findings, an overview of the methodology, and significance of the study. Under the significance of the study, I demonstrated how the study contributes to the theory, policy, and practice of OSH in Malawi. In this chapter, I further presented how this thesis is organised in terms of chapters. In the next chapter, I highlight a broader context for Malawi within which I conducted the study. 18 Chapter 2 Setting the context 2.1. Introduction In this chapter, I present background information about Malawi. This background information provides a broader context for the study. Firstly, in this chapter, I highlight the socio-economic and administrative contexts of Malawi. Thereafter, I narrow the focus to the architecture of health service delivery to illustrate the location of clinical officers (COs) in the provision of healthcare in Malawi. 2.2. Socio-economic context Malawi is a landmass in Southern Africa measuring 118,484 square kilometres, of which 29,600 square kilometres are covered by water (Malawi Government, 2017a). Malawi shares international boundaries with Zambia, Mozambique, and Tanzania, as shown in Figure 3-2 (below). The territory was first declared a British Central African Protectorate in 1891 before being renamed Nyasaland Protectorate on 6 July 1907. On 6 July 1964, Nyasaland became an independent country known as Malawi under a prime minister called Dr Kamuzu Banda, who was a medical doctor by profession. Malawi is a low-income country whose gross domestic product (GDP) per capita is estimated at USD 637 (World Bank, 2020). The total population of Malawi is 17.6 million, of which 84 per cent lives in rural areas (National Statistical Office, 2019). The country registers a population density of 186 persons per square kilometre, which is considered one of the highest in Southern Africa (National Statistical Office, 2019; World Health Organization, 2017). The mortality rate for the under-five population (per 1,000 live births) is 38.6 per cent, while life expectancy is estimated at 64.7 years (United Nations Development Programme, 2020; World Bank, 2020). Malawi’s human development index (HDI) value for 2019 was 0.483, which is position 174 out of 189 (United Nations Development Programme, 2020). Against this backdrop, about 52.6 per cent of Malawi’s population is multidimensionally poor, while 28.5 per cent is classified as vulnerable to multidimensional poverty (United Nations Development Programme, 2020). 19 2.3. Administrative context Malawi is divided into three provinces which are called regions namely: northern region, central region and southern region (Malawi Government, 2017a). The three regions are divided into 28 districts as shown in Table 1-2 below. Table 1-2: Regions and districts of Malawi Region Districts Northern 6 districts: Chitipa, Karonga, Likoma, Mzimba, Nkhata Bay, and Rumphi. Central 9 districts: Dedza, Dowa, Kasungu, Lilongwe, Mchinji, Nkhotakota, Ntcheu, Ntchisi, and Salima Southern 13 districts: Balaka, Blantyre, Chikwawa, Chiradzulu, Machinga, Mangochi, Mulanje, Mwanza, Nsanje, Thyolo, Phalombe, Zomba, and Neno. Traditional authorities (TAs) are sub-divisions of districts, which are composed of villages under the jurisdiction of local leaders called chiefs (Malawi Government, 2017a). Furthermore, each district is composed of constituencies that members of parliament (MPs) represent in the national assembly (Malawi Government, 1998b, 2013, 2017a). A constituency in each district, is composed of wards that are each represented by a member of the district council called a councillor (Malawi Government, 1998b, 2013). 20 Figure 3-2: Administrative map of Malawi Source: Nations online (N/A). https://www.nationsonline.org/oneworld/map/malawi-administrative- map.htm As shown in Figure 3-2, there are four cities located in each of the four districts, namely: the city of Mzuzu (located in the Mzimba district) in the northern region; the city of Lilongwe, which is also the capital city, located in the central region; the city of Zomba (the former capital city until 1975); and the city of Blantyre, which is located in 21 the southern region. Each of the 28 districts except Blantyre, Zomba, Lilongwe, and Likoma has at least one district hospital that is owned by the state. Furthermore, there is a state-owned central hospital in each of the four cities. However, the city of Zomba has two central hospitals, i.e., a general hospital and a mental hospital. The central and district hospitals offer an extensive variety of preventive and curative services such as anaesthesia, ear, nose, and throat (ENT), orthopaedics, outpatients, admissions, HIV/AIDS and TB treatment, pharmacy, family planning, paediatrics, physiotherapy, surgery, radiology, laboratory, maternity, and antenatal care. Out of the 28 districts, I conducted the study in five districts, as shown in Table 2-2 below. These districts are Nkhatabay, Blantyre, Chikwawa, Mulanje, and Balaka. Out of the five districts, Blantyre is designated as a city with increasing rates of urbanization, while the rest of the districts are classified as rural areas (National Statistical Office, 2019). This is why, among the five districts, Blantyre has the highest proportion of the total population in the country despite constituting the lowest percentage of the country’s total land mass, as shown in Table 2-2. Furthermore, being an urban area, Blantyre has more privately-owned clinics and hospitals than the other four districts as shown in Table 2-2. The central hospital in Blantyre, as indicated in Table 2-2, is called Queen Elizabeth Central Hospital. It serves as a referral health facility for the district hospitals in the southern region, such as Mulanje, Chikwawa, and Balaka, among others (Malawi Government, 2018a). The district hospitals are used as referral health facilities for the village clinics, health posts, dispensaries, and other health facilities that are located in a particular district, as shown in Table 2-2. Most of the village clinics, health posts, and dispensaries at the district level are owned by the state. 22 Table 2-2: Profiles of 5 districts where study sites are located Name of District Location Land mass (square km) Population (a s percentage of Malawi’s total population) State-owned district hospital (s) Other health facilities Nkhatabay Located along a lakeshore in northern region 4,182 (4% of Malawi’s total land mass) 1.6 - 1 district hospital - 1 rural hospital - 212 health posts - 142 village clinics - 3 dispensaries - 18 health centres2 Blantyre Located in southern region. Categorised as a city 2,012 (1.7% of Malawi’s total land mass) 7.2 - No district hospital - 1 central hospital - 28 health centres - 129 under 5 clinics - 140 private clinics - 6 private hospitals - 1 CHAM hospital Chikwawa - Located in southern region. - Shares boundaries with Mozambique on western side and Blantyre in North East 4,755 (5% of Malawi’s total land mass) 3.2 - 1 district hospital - 1 rural hospital - 30 health posts - 154 village clinics - 5 dispensaries owned by parastatals - 15 health centres - 1 CHAM hospital Mulanje - Located in southern region - Shares boundary with Mozambique on southern side 2,056 (2.2% of Malawi’s total land mass) 3.9 1 district hospital - 190 health posts - 21 health centres - 28 private clinics (most of them owned by tea estate companies) - 1 CHAM hospital Balaka - Located in southern region - Previously a portion of Machinga district until 6 June 1998 2,193 (2.4% of Malawi’s total land mass) 1.5 1 district hospital - 95 village clinics - 260 under 5 clinics - 4 dispensaries - 12 health centres3 Sources: Nkhatabay District Council (2020), Mulanje District Council (2017), National Statistical Office (2019), Blantyre District Council (2018), Chikwawa District Council (2020), Balaka District Council (2018b), Balaka District Council (2018a). 2 2 are owned by CHAM while 1 is privately owned. 3 6 are owned by CHAM while 2 are privately owned 23 2.4. The architecture of healthcare services in Malawi In this section, I shed light on the architecture of health service delivery in Malawi with two intentions. The first intention is to illustrate how healthcare is delivered in Malawi. The second intention is to illustrate the location of clinical officers (COs) in the provision of healthcare in Malawi. 2.4.1. The organisation of healthcare services Healthcare in Malawi is provided through three sub-sectors. The three sub-sectors are the public (free), private (for-profit), and private (not-for-profit) sectors (Malawi Government, 2017a). The public sub-sector is the major healthcare provider and includes all health facilities owned by government ministries, district, town, and city councils (Malawi Government, 2017a). The private for-profit sub-sector includes all privately-owned health facilities, while the private not-for-profit sub-sector comprises health facilities owned by faith-based institutions, non-governmental organisations (NGOs), and statutory corporations (Malawi Government, 2017a). The major faith- based provider is a grouping of mission hospitals called the Christian Health Association of Malawi (CHAM), which accounts for approximately 29 per cent of all health services (ibid). According to the Malawi Government (2017a), healthcare in Malawi is organised at four levels that are interconnected as follows: i. Community level- provided by community health workers (e.g. health surveillance assistants), health posts, dispensaries, village clinics, and maternity clinics; ii. Primary level- provided by health centres and community hospitals; iii. Secondary level- consists of state-owned hospitals and CHAM hospitals at the district level; iv. The tertiary level- consists of 5 state-owned central hospitals located in the four major cities of Blantyre, Zomba, Lilongwe and Mzuzu. The community, primary, and secondary levels (across the three sub-sectors of health service delivery) fall within the district health system under the jurisdiction of the local councils. At the district level, health services are coordinated by a District Health Management Team (Borghi et al., 2018; Bulthuis et al., 2021; Malawi Government, 2017a). The District Health Management Team (DHMT) is based at the district hospital. Block grants emanating from domestic sources, i.e., tax revenue, and from external sources in the form of general budget support are annually allocated to the districts by the Ministry of Finance to cater for district-level health activities (Borghi et 24 al., 2018). In addition, international cooperating partners collectively contribute separate funds into one basket called Sector Wide Approach (SWAP) to financially support health services at the district level, among others (Borghi et al., 2018; Malawi Government, 2017a, 2018b). The district hospital attends to cases referred from health facilities at the community and primary levels within a particular district. The tertiary level is managed by the central government through the Ministry of Health (Malawi Government, 2017a, 2018a). The central hospitals also serve as both primary and secondary healthcare facilities due to the lack of district hospitals in the four cities where the central hospitals are located (Malawi Government, 2018a). Various non- governmental organisations (NGOs) and institutions of higher learning also use the central hospitals for training and research (ibid.). However, there have been reforms to transfer the management of central hospitals to boards of trustees (Malawi Government, 2018a). The reforms are currently ongoing. From 2004 to 2016, the Essential Health Package (EHP) was a policy framework that guided the free provision of healthcare across the four levels of health service delivery (Malawi Government, 2017a, 2017c). When there was no state-owned health facility within a 5-kilometre radius, the Ministry of Health contracted with CHAM to provide free healthcare via service level agreements (ibid.). Following an evaluation, in 2017 the EHP was collapsed into two: the Basic Healthcare Package (BHP) and the Basic Health Care Package plus (BHP+) (Malawi Government, 2017a). The BPH performs the functions of the EHP, i.e., offering guidance on interventions delivered without charge to the general public, while the BHP+ provides indications for priority areas in case the BHP is expanded given the availability of financial resources (ibid). Across the public sub-sector and CHAM facilities, there are a total of 37,926 health professionals who are employed out of a total of 62,269 established positions (Malawi Government, 2018b). The statistics show that at health facilities owned by the state, there are 0.21 medical doctors per 10,000 population, 3.44 nurses per 10,000 population, and 0.82 COs per 10,000 of population (Malawi Government, 2018c). According to the World Health Organization (2006), a country with less than 25 health professionals (i.e., doctors, nurses, and others) per 10,000 population cannot achieve adequate coverage of critical primary health care interventions. 25 More recent statistics on the health workforce in Malawi were reported in a survey on the human resources for health in Africa that was conducted by the World Health Organisation (2021). This survey showed that out of 47 African countries, only 4, namely: Seychelles, Namibia, Mauritius, and South Africa, had a density of doctors, nurses, and midwives per 1,000 population that reached or exceeded the Sustainable Development Goals (SDG) threshold of 4.45 health professionals per 1,000 population. In contrast, Malawi is among the 16 (out of 47) countries in Africa reporting the lowest densities that fall within the range of 0–1 health professional per 1000 population (World Health Organisation, 2021). The acute shortage of health professionals therefore partly explains why Malawi is confronted with a growing burden in efforts to provide healthcare to the general public. Among others, such a burden is manifested through the high prevalence of communicable diseases, high incidences of maternal and child health problems, and an increasing burden of non-communicable diseases (Malawi Government, 2017a; World Health Organisation, 2017). 2.4.2. Location of clinical officers in healthcare service delivery Before the opening of the University of Malawi’s College of Medicine in 1991, young Malawians were studying medicine in Southern Rhodesia (now Zimbabwe), Northern Rhodesia (now Zambia), North America, and Europe (Broadhead & Muula, 2002; Muula et al., 2016). Upon qualifying as doctors abroad, most of them either never returned at all or took years to come and practise medicine in Malawi (Broadhead & Muula, 2002). They working conditions abroad were generally perceived to be far much better than in Nyasaland under colonial rule and later Malawi under a tyrannical one-party state. Given the rapidly growing population and rising healthcare demands, there was a severe shortage of medical doctors at the secondary and tertiary levels of health service delivery by 1970 (Broadhead & Muula, 2002; Dovlo, 2004; Gajewski et al., 2019). In response to this critical shortage, in 1976, the Ministry of Health introduced a cadre of mid-level health professionals called COs as substitutes for medical doctors (Muula, 2009; Thetard & Macheso, 2004). “As you may know already, Dr Daniel Malikebu and Dr Kamuzu Banda were the first two people from this country to qualify as medical doctors in 1917 and 1937 respectively. They both studied at Meharry Medical College in Nashville, Tennessee (USA). The former took almost a decade to return home to practice. The latter returned home 20 years after he 26 qualified as a medical doctor in the USA. That continued to be the trend with many others who eventually left this country to study medicine abroad. They took long to return home to practice while some of them decided to remain abroad for good when their expertise was greatly needed in this country. Until 1991, we never had a medical school in the country to produce medical doctors locally. So, there was a crisis of shortage of medical doctors in the country. Until late 1976 when clinical officers emerged on the scene as substitutes for medical doctors. These clinical officers were introduced as a temporal solution to this crisis” (Conversation, external referee- public health researcher). Following completion of O' level education, candidates for CO positions are trained locally at Malawi College of Health Sciences for a 3-year diploma course in anatomy, physiology, pharmacology, paediatrics, medicine, surgery, obstetrics, and gynaecology (Bradley & McAuliffe, 2009; Chilopora et al., 2007; Gajewski et al., 2019; Grimes et al., 2014). The Malawi College of Health Sciences was established on 21 June 1996, following a merger of three training institutions, namely the Lilongwe School of Health Sciences, the Medical Assistants Training School, and the Zomba School of Nursing (Malawi College of Health Sciences, 2022). Before this merger, the COs were trained at the Lilongwe School of Health Sciences, which opened its doors on 12 July 1976, under the name Medical Auxiliary Training School (Malawi College of Health Sciences, 2022). After completing a 12-month internship at a central or district hospital, trainees for the CO position are licenced to practice independently at secondary and tertiary levels of health service delivery (Bradley & McAuliffe, 2009; Chilopora et al., 2007; Gajewski et al., 2019; McAuliffe, Bowie, et al., 2009; McAuliffe, Manafa, et al., 2009; Mkandawire et al., 2008; Muula, 2009). At the hospitals, the COs are deployed to various departments and units depending on the areas in which they specialised during their training. Some hospitals have a system called rotation whereby hospital staff, including COs, are sometimes shuffled to other departments or units. At the district and central hospitals, the COs provide various services, including orthopaedics, physiotherapy, HIV/Aids and TB treatment, family planning, paediatric surgery, radiology, pharmacy, laboratory, and antenatal care. 27 The first cohort of locally trained COs commenced clinical practice in 1980 upon completion of a 3-year training course and 12-month internship (Thetard & Macheso, 2004). Before this cohort was enrolled in 1976 for CO training locally, there was another group that had been dispatched for clinical training in France. When trainees from this cohort returned to Malawi after completing their training in France, they became the first COs in 1976. Some of them were immediately deployed as lecturers at the Medical Auxiliary Training School, which had just been established in the same year. Until a few years after the opening of the College of Medicine in 1991, most of the doctors at public hospitals were expatriates on fixed contracts deployed by Malawi’s cooperating partners (Palmer, 2006). “There were 42 in the first cohort of locally trained clinical officers in 1976. But only 21 of us completed the training. In 1980, 21 of us were immediately dispatched to work in district hospitals across the country. I was sent to Nsanje District Hospital where I worked for 2 and half years before being deployed to teach subsequent cohorts of clinical officers at the Medical Auxiliary Training School. In the districts, we could independently perform all sorts of duties that were supposed to be undertaken by medical doctors. By then, there were a handful of doctors at public hospitals who were mostly expatriates” (Interview, retired clinical officer 01). Over the years, skill development programmes have been introduced for COs to upgrade from diploma level to bachelor of science (BSc) level in various disciplines (Gajewski et al., 2019). One such programme is the Clinical Officer Surgical Training (COST) Africa Project (2011–2016), through which a BSc course in general surgery was offered at the College of Medicine (Gajewski et al., 2019). The first cohort under this programme included 17 COs drawn from 8 district hospitals who were trained in common emergency and elective procedures (Gajewski et al., 2019). There is no government sponsored programme or initiative to upskill COs to become qualified medical doctors. The public sub-sector employs 1,045 COs out of 2,935 established positions, while a total of 266 COs out of 1,021 established positions work in CHAM facilities (Malawi Government, 2018c). While some COs are deployed to central hospitals, a bulk of them work at the secondary level of health service delivery, such as state-owned 28 district hospitals and hospitals run by CHAM (Gajewski et al., 2019; Muula, 2009; Thetard & Macheso, 2004). Since the inception of CO training in Malawi in 1976, some COs have eventually proceeded to obtain postgraduate qualifications in various disciplines, such as master and doctoral (PhD) degrees. The list of such COs includes names like Prof. Felix Salaniponi, Dr Leslie Phiri, Dr Biswick Mwale, Dr David Mtotha, Dr Wilfred Chalamira Nkhoma, Mr Raphael Piringu, Mr Edwin Nkhono, Mr Alan Macheso, and Hon. Yusuf Mwawa. 2.4.3. Social dialogue in the health sector In the health sector, there are three main categories of employers. The first one is the government which is the employer of health workers in state-owned health facilities. The second category of employers is CHAM which brings together all employers of health facilities owned by church institutions. The other main category of employers in the health sector comprises owners of profit and non-profit making health facilities or firms. The health workers in Malawi belong to various organisations as shown in Table 3-2. Table 3-2: Organisations of health workers in Malawi No. Name of organisation Acronym Nature of the organisation 1. Physicians’ Assist