Abstract
Medical Assistants and Clinical Officers perform the bulk of clinical care in Malawi's hospital and health centres. These cadres of health workers are trained at two centres; the Malawi College of Health Sciences and the Malamulo College of Health Sciences. The training of medical assistants and clinical officers is continually threatened by economic and social influences. Adamson Muula had an interview with Mr Panulo, clinical officers' trainer and Principal of Malamulo College.
AM: Would you tell me about your ‘early beginnings’ Mr Panulo?
FP: I was born on 6th July 1950 in National Authority Mabuka in Mulanje. It was a family of 11 children, 7 boys and 4 girls. I spent my primary school days at Naluso Primary School in Mulanje and Malundani School in Kasupe, now Machinga from where I was selected to Malosa Secondary School in 1968. That same year, the government directed that all secondary school pupils should move to study in their home districts. I was therefore transferred to Mulanje Secondary School where I was from 1968 to 1912.
AM: Then how did you end up at Malamulo? What motivated you to the health profession?
FP: When I was doing my primary school at Malundani in Kasupe, I was staying with my uncle and aunt. Later my aunt was pregnant and when she was due to deliver, she had complications. That time the nearest hospitals were either Mangochi or Zomba. The health centre at Malosa or Chilema could not handle complicated deliveries. Transport was a problem. There were only one or two buses everyday passing by our village. By the time my aunt was taken in a bus to Zomba Hospital, it was too late. She died on the way. I guess this experience influenced me more than anything else.
But there was also an element of negative motivation. My uncle was a primary school headmaster at Malundani. His house would always be leaking in the rainy season. The medical assistants' house at the nearby health centre was in far much better condition. I didn't want to follow my uncle's foot steps.
When I finished secondary school. I was invited to train as a primary school teacher. I chose the medical assistants' course although the teachers' training college was offering tuition for free. Some of my friends said I had lost my mind. Why opt for a college where you were going to pay for tuition? More over, teachers' training only ran for 2 years while clinical medicine training took 4 years.
AM: But you have not yet told me how you ended up working for Malamulo Hospital and not elsewhere?
FP: When I qualified in 1977, I was invited to join the Blantyre Adventist Hospital as a dental assistant. Malamulo Hospital also asked me to stay. One of my influences had been Dr Gilbert Burnham who was the Medical Director at Malamulo. I chose Malamolo Hospital. Dr Burnham is now Professor of Public Health at Johns Hopkins University, Baltimore, USA.
I have worked in almost all hospital departments. For instance, between 1978–79 I was administering anaesthesia in theatre. In 1919, I was theatre in-charge and surgical (operations' assistant. I joined the Community Health Department at Malamulo in 1979. I have worked in all hospital wards in various capacities. And all qualified staff at the hospital are called on to teach and supervise students from time to time.
AM: How do you compare the training in your times and the present System?
FP: Some things have changed but the overall quality has been maintained, perhaps improved. I was in the first group of students to do a clinical officers' course in Malawi. My training ran from 1913 to 1978. We started with what was called “pre-training”. This phase involved the basic sciences; Anatomy, Physiology, Microbiology and Parasitology. But we also studied hygiene and infection prevention and control and learned medical terminology. There after, there was a barrier examination for one to be accepted into mainstream medical assistants'/clinical officers' training.
AM: What do you mean by “medical assistants'/clinical officers” training?
FP: Well, I started my training, we were not just doing one thing. After two years, we sat for certificate examinations in Nursing and Midwifery and Health Services Management. As I said, we were the first group in Malawi to study for a Diploma Course in Clinical Medicine. Our diploma was not recognised by the regulatory authorities at the time. That was the Ministry of Health; there was no Medical Council of Malawi at that time. So, at the end of the 4 years we ended up graduating with the Diploma recognised by none other than Malamulo College and a government's medical assistants' certificate recognized by everyone else.
AM: Why would the authorities not recognise the Malamulo diploma?
FP: I guess the feeling at the time was, “how can you start offering diplomas when the government training schools are not doing that?”. The government had to start and all of us to follow afterwards. However, we continued training our “medical assistants” to clinical officer level until 1993 when we were stopped form doing so by the Medical Council of Malawi. The reason given at the time was that we would be confusing people if we continued offering both a clinical' officers' diploma and the medical assistants' certificate. In 1998, we graduated the first class of government-recognised diplomate clinical officers. But now our diploma is recognised both nationally and internationally.
AM: Do you mean graduates of your College are working abroad?
FP: This fact is both sad and sweet. Yes, we have always had students from abroad, countries such as; Tanzania, Kenya, Zambia and as far as the Democratic Republic of Congo, Sierra Leone, Ethiopia and Ghana. Our foreign students pay USD2,000 per year as tuition fees. When they qualify, they return to their home countries. Some Malamulo trained Malawians are also practicing abroad. This is the sweet-sour fact. But what with poor remuneration and unclear prospects of career advancement within Malawi? The majority of our former students are however within the country and we are proud of the fact.
AM: How does one become a clinical officers' tutor?
FP: Almost all of our tutors are graduates of Malamulo. When one finishes their internship and we believe they have potential to impart knowledge to others, we would identify them for teaching. We however encourage clinical experience extending over a year before they join us, but this is not always possible. We also have medical doctors who are on our teaching roll. Malamulo has 5 doctors at the present.
AM: What are the challenges facing clinical officers' training in Malawi?
FP: I would say we have done very well so far. But funding continues to be an illusive issue. There are indications that the money that we get from the Christian Health Association of Malawi (CHAM) may not be sustainable. Our students have already been paying K15,000 per year and we are hesitating to increase the tuition fees as parents and guardians are already hard-pressed. There is some talking to the effect that come December 2001, there may not be any CHAM money going to training institutions. Perhaps we should figure out how we can generate more income without disadvantaging anybody too much.
A further problem regards availability of teaching resources such as textbooks. Many books on basic sciences and clinical medicine are not designed to cater for clinical officers' training. But we have always done our best to adapt the teaching materials.
The other problem is that because of resource constraints, we have not been able to increase enrollment to match demand. Remember, less than a hundred clinical officers and doctors are graduating each year from all training institutions in the country. There is also increased wastage of staff in the country currently estimated at about 3%. We must train more than are lost just to maintain the status quo. But even if we were to do that, the population of Malawi is not stagnant. It is always growing, now at 1.9% per year.
Clinical officers, in general, do not have a clear career structure. Some of us have been lucky to be where we are now. Most of our colleagues may not see the light at the end of the tunnels.
This area needs our attention. and urgently so.
AM: What other ‘major’ responsibilities have you had in career?
FP: I moved from the Community Health Department of Malamulo Hospital to head the training college in 1996. Between 1991–92, I got a Postgraduate Diploma in International Health from Queen Margaret University College, Edinburgh Scotland through a British Council training fellowship. From 1992 when I returned to Malawi, I was Director of Community-Health Projects. We were the first to start the community-base distribution (CBD) of a modern contraceptive in Malawi. CBD agents were allowed to distribute only condoms at the time. We integrated family planning in maternal-child health clinics.
AM: Has your responsibilities always revolved around Malamulo and nothing else other than Malamulo?
FP: I was member of the Ministry of Health and Population's Quality Assurance Task Force. I also sit on the sub-committee on training in the Medical Council of Malawi. I am also member of the Board of Governors of the Malawi College of Health Sciences. I have served on a number of government's committees and projects. In 1982, I was trained as an Ophthalmic Assistant In Tanzania, studying ophthalmology and optics. I started an eye clinic and community identification and correction of low vision later.
AM: I know you are now doing a Masters with interest in community health?
FP: I guess every health worker must be a community-oriented person. I believe I was greatly influenced after participating in the All Africa Conference, held in Nairobi in 1919. This conference followed the Alma Ata Declaration of 1978. From that time, I set my eyes on broader health care delivery.
AM: What do you see as the future of Malamulo College?
FP: Yes, we have been around for long enough for us to move into the future. Malamulo Hospital started training medical auxiliaries/dressers and other cadres of health workers way back in 1908. We are currently engaged in intensive capacity building of teaching staff. Three of our tutors are pursuing degree courses at Mzuzu University. Another 3 members are doing their Masters of Public Health with Loma Linda University. We are working towards offering degree courses in the next 5 or so years. Whether this materializes or not is another thing. It is not wrong to dream!
AM: Thank you Mr Panulo. I hope that your dreams are realised!