Globally, 57 countries face critical heath workforce shortages and more than four million health workers are needed to fill this gap . Such shortages of human resources for health combined with the double burden of infectious and chronic diseases contribute to increased mortality and morbidity, impede the achievement of the health-related Millennium Development Goals, and hinder economic growth in low- and middle-income countries. Given this human resource gap, particularly in rural areas, there is renewed interest globally in the potential for community health workers (CHWs) to take on an expanded role in strengthening health systems .
Many countries developed national programmes for CHWs following the Alma-Ata Declaration on primary health care in 1978. CHWs are the first point of care and typically work at the household level . They are widely employed across Africa and Asia and to a lesser extent South America and occasionally in the USA and UK. Typical roles include: nutrition, maternal and child health promotion, childhood immunization, infectious disease control and implementation of noncommunicable disease interventions .
The World Health Organization (WHO) supports the use of CHWs in countries such as Malawi with a shortage of health workers (two doctors per 100,000 people) and a high disease burden . The WHO stresses the importance of having a national framework to guide task-shifting, clearly defined roles, consultation with all cadres, strong training, adequate supervision and regular assessment .
Several existing systematic [5, 6] and nonsystematic reviews [7, 8] provide evidence that CHW interventions can be effective in malaria prevention activities including the distribution of insecticide-treated nets and that CHWs can increase immunization coverage, improve breastfeeding rates, and show promising benefits in improving tuberculosis (TB) treatment outcomes and neonatal survival when compared to usual care. There is limited information regarding CHW training, supervision, prioritization of tasks, and challenges faced across multiple service delivery responsibilities. Amidst the research evidence, few studies have given voice to CHWs in low- and middle-income countries [9, 10].
CHWs in Malawi are called Health Surveillance Assistants (HSAs). Initially they were called Cholera Assistants when first recruited in 1973 by the public health unit to fill a human resources gap and manage a large cholera outbreak . Following the Alma-Ata declaration the position was renamed. In 1998, the Ministry of Health (MOH) recognized a growing need for the provision of health services at the community level and renamed Primary Health Care workers to the current title of HSA while making HSAs position within the health sector permanent [11, 12]. HSAs are now employed within the Environmental Health Department . According to the HSA job description, Assistant Environmental Health Officers are the formal supervisors of HSAs, however the more experienced Senior HSA position, also called HSA supervisor, provides the majority of direct supervision to HSAs .
According to the job description, the qualification of HSA is awarded to those who have completed the Malawi School Certificate of Education or Junior Certificate of Education and the MOH-approved HSAs’ pre-service training programme . As the role of the HSA has evolved, so too has the HSA pre-service training programme. This was initially of six weeks duration but has been gradually increased to eight, then ten and now twelve weeks . According to MOH documents, 5% of HSAs nationally are yet to receive pre-service training .
Today, HSAs comprise 30% of the health workforce in Malawi and they are often the only health workers serving rural communities where they are expected to reside . The targeted ratio of HSAs to population is 1:1,000 . The cadre is largely responsible for community-level delivery of the MOH Essential Health Package, being the minimum services provided to all Malawians free of charge . Most recently, as part of the Essential Health Package, HSAs have been asked by the MOH to deliver community case management (CCM), an extension of the integrated management of childhood illness (IMCI) approach at the community level . The MOH considers the three primary roles of the HSA to provide promotive, preventive and curative care; promote community participation in health care activities and to provide disease surveillance services at the community level .
It has been well documented that new activities such as microscopy and HIV testing and counselling are regularly being added both formally and informally to the HSA role and existing activities are being scaled-up using HSAs [13, 16]. Generally, the effectiveness of scale-up programmes involving CHWs has been difficult to determine given the variation in the scale-up approach and the difficulties measuring outcomes [5–8, 17]. However, locally the Médecins Sans Frontières experience in Thyolo district Malawi provides some evidence of feasibility and good outcomes for a programme of decentralized HIV care to clinics and community settings using task-shifting in which HSAs provided the HIV testing and counselling, and, treatment initiation was transferred to non-physician clinicians . Between 2003 and 2009, the programme achieved universal access targets and achieved significant gains in human resources efficiency . As such, the MOH continues to train and certify HSAs in HIV testing and counselling with the help of nongovernmental organizations (NGOs), such as Médecins Sans Frontières, who recognize the need for task- shifting this role to HSAs given the severe shortage of higher-level health workers . The MOH has also reported that it aims to expand certain programmes, such as TB treatment, with HSAs as the primary providers .
A situational analysis of the HSA cadre in Zomba district Malawi was undertaken in order to comprehensively understand the HSA cadre’s role, training system and supervision. Reported here are the findings from the cross-sectional assessment of the HSAs’ performed versus documented roles and the examination of prioritization of tasks by HSAs, their supervisors and policy-makers.