From Concession to Contract: Collective Bargaining as the Engine for Health System Resilience in Malawi

Abstract

Nurses and midwives form the primary foundation of healthcare delivery in Malawi, carrying out the majority of direct patient care across all levels of the health system. In rural areas—where over 80% of the national population resides—nurses and midwives account for over 90% of all frontline healthcare providers (ICAP, 2016). They serve as the universal first entry point for 90% of individuals seeking care at local health centers and community facilities (Bvumbwe & Mtshali, 2018). Within maternal and child health, nurse-midwives operate as the primary providers of essential obstetric and newborn care, managing the entire maternal continuum from antenatal visits through labor, delivery, and immediate postnatal care (Muller et al., 2021; Rouse et al., 2024). Furthermore, due to the critical shortage of Medical Doctors, their clinical scope has expanded significantly; nurses routinely run specialised outpatient services, initiate antiretroviral therapy (ART) for HIV management, treat tuberculosis, and stabilise pediatric and medical emergency cases.