Where does healthcare worker time go? Evidence from a time-and-motion study in Malawi

Low- and middle-income countries face critical shortages of healthcare workers (HCWs) and funding for human resources for health (HRH), while patients often receive less care time than expected. Understanding how the existing workforce capacity is used is therefore essential for improving health system performance in resource-constrained settings. We examined HCW time-use patterns in Malawi using data from a time-and-motion study conducted between January and May 2024, which recorded activities across multiple cadres, days, and representative health facilities in the healthcare system. Across cadres, median daily working time, including breaks, was 7.35 hours (IQR 4.40-8.35), approximately 1.65 hours below the typical contracted schedule. HCWs spent most time on direct patient care: 2.82 hours per day (IQR 1.89-3.97), accounting for 48% of total working time (IQR 30%-67%). Administrative tasks accounted for 0.30 hours (IQR 0.00-1.23; 5.21%, IQR 0%-18%) and break time remained consistent with the contracted expectations at 1.25 hours (IQR 0.00-2.12; 18%, IQR 0%-28%). Unallocated time, defined as time neither work-related nor recorded as breaks, was 0.72 hours (IQR 0.02-1.92; 12%, IQR 0%-29%), mainly attributed to the absence of patients based on available information. Median patient load was 21 per staff member per day in outpatient care (IQR 12-35), 12 in inpatient care (IQR 7-18), and 14 in emergency care (IQR 10-23), with median time per patient of 3 (IQR 1.0-6.5), 6 (IQR 2.5-14), and 10 (IQR 5-20) minutes, respectively. These measures, particularly time per patient, vary by cadre, facility type, facility ownership, region, and service area. The findings present a first system-wide picture of HCW time use in a low-income setting and can inform health systems planning. The gap between contracted and actual working time and unallocated time suggests scope to improve workforce utilisation, while high patient loads highlight the need for sustained HRH investment and workforce expansion. Key MessagesO_LIIn low- and middle-income countries with persistent health workforce and human resources for health (HRH) funding constraints, it is essential to understand how healthcare worker (HCW) time is utilised in practice to identify opportunities to improve service delivery and overall health system performance. C_LIO_LIBased on a time-and-motion study in Malawi health system, we observed that HCWs worked a median of 7.35 hours per day (including breaks), below the typical contracted schedule. Although most working time was devoted to direct patient care, the patient-facing time was limited relative to high patient loads, with short service time per patient, particularly in outpatient settings. The time-use patterns also varied across HCW cadres, facility types, regions, facility ownership, and service areas. C_LIO_LIWorkforce planning should address both utilisation and capacity: reducing avoidable unallocated time may improve efficiency, but high patient loads and short service time per patient indicate that sustained HRH investment and workforce expansion remain essential. C_LI