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| Paper Title: | The role of Health Surveillance Assistants in Promoting Preventive Health in Malawi: Case of Mulanje District |
| Authors Name: | Fred Masoadyera Yiwombe |
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IJNRD_213176
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| Published Paper Id: | IJNRD2401292 |
| Published In: | Volume 9 Issue 1, January-2024 |
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| Abstract: | ABSTRACT The role of Health Surveillance Assistants in Promoting Preventive Health in Malawi: Case of Mulanje District Malawi is one of the underdeveloped countries yet to achieve optimal health outcomes. Life expectancy remains low at 47 years. Over half of the country’s total disability-adjusted life years are a result of the top four leading causes– HIV/AIDS, lower respiratory infections, malaria, and diarrheal diseases. Health Surveillance Assistants make up over half of about 17,000 health workers in Malawi. This study investigated the role of Health Surveillance Assistants in promoting preventive health in Mulanje District of Southern Malawi.The study focused on HSA roles, workload, training, capacity challenges and coping measures to their work. The study was underpinned by the competence motivation theory to explain HSAs’ motivation to participate, persist, and work hard as key community health workers. The study used a mixed research design of qualitative and quantitative research designs. Specifically, the study got insights from exploratory and descriptive research designs. Data was collected from 59 HSAs using a questionnaire. The data has been analysed using descriptive statistical analysis and thematic analysis. The findings show that HSAs perform broader duties in community health, family health, environmental health and prevention and control of common community diseases with managerial and administrative duties performed by senior HSAs (supervisors). HSAs face a huge workload mainly because their duties are too broad, they serve too many people, NGOs use us for community work and that there are few community health workers (HSAs). The workload challenges can be addressed by employing more HSAs to reduce HAS to people ratio, have more training for the effective work of HSAs, have new system (technology) on reporting activities so as reduce time spent on writing reports, ease mobility challenges by providing HSAs with motorcycles, and providing HSAs with laptops for compiling information and executing their duties. HSAs face training capacity challenges mainly due to in adequate training time such that the training covers too much content and does not provide for adequate practical for hands on experience. The HSA capacity challenges are increased by the communities’ expectation that HSAs are considered as not just community health workers but also as nurses and doctors. HSAs to cope with the magnitude of work by using time management, working as a team and making good use of village structures like village health committees. The study recommends that Malawi government should increase number of HSAs, increase HSA training to at least 1 year and provide reliable certification similar to other health qualifications. 1. Background Malawi is a landlocked country in Southern Africa, sharing its borders with Mozambique, Zambia, and Tanzania. The country has an estimated population of 20.41 million (2022) with an annual growth rate of 2.6%. Malawi is one of the poorest countries in the world. Malawi’s economy remains predominantly an agricultural country, with agriculture, forestry, and fishing contributing 28% of GDP. Currently, GDP per capita is approximately $380, and given that inflation and population growth currently outpace economic growth, average living standards are falling. In 2010-11, 29% of households lived under the international poverty line of $2 per day. Poverty remains particularly prevalent in rural areas, where over 14 million people –more than 80% of the population – live. Malawi is one of the underdeveloped countries yet to achieve optimal health outcomes. Life expectancy remains low at 47 years. Over half of the country’s total disability-adjusted life years are a result of the top four leading causes– HIV/AIDS, lower respiratory infections, malaria, and diarrheal diseases. Malawi has reduced its child mortality rate, leading to achievement of Millennium Development Goal (MDG) 4. However, other indicators remain stagnant or even face declines. For example, the percentage of facilities able to deliver Malawi’s essential health package (EHP) fell from 74% in 2011 to 52% in 2015. Therefore, fewer people are accessing critical health services. The Malawi health sector operates under a decentralised system guided by the Local Government Act (1998). The Act delegates authority and funding from central government ministries to district assemblies, who guide health sector planning, budgeting, procurement, and service delivery at district and community levels. At central level, the Ministry of Health (MoH) sets strategic direction and formulates sector-wide governing policies. 29 district health offices oversee services provided in and outside of the district hospital. Five Zonal Health Support Offices (ZHSOs) provide technical support to districts in planning, delivery, supervision, and monitoring of health services. The decentralised system has four tiers of service delivery: community, primary, secondary, and tertiary. Community services include those delivered through community initiatives, village clinics/health posts, and community health workers. Primary includes dispensaries, maternity facilities, health centres, and community and rural hospitals. District hospitals deliver secondary-level inpatient and outpatient services and serve as referral facilities for the primary level of care. At tertiary level, central hospitals serve as referral facilities for the district hospitals and provide additional services in their regions. Central hospitals also have the mandate to offer professional training, conduct research, and provide support to the districts. While the Ministry of Local Government and Rural Development (MoLGRD) is responsible for health care service delivery at community, primary and secondary levels, the MoH remains responsible at tertiary level. Community-based primary care is gaining prominence in Malawi and many other countries. Globally, community-based primary healthcare is critical to achieving the global health milestones put forward by the Sustainable Development Goals (SDGs). SDG 3 aims to ensure healthy lives and promote well-being for all ages by 2030, including the target to achieve universal health coverage by 2030. Other SDGs focused on poverty, hunger, education, gender equality, and water and sanitation also imply ambitious goals for the health sector. Overall, the SDG targets related to health have a much broader scope than the health-related MDGs 4 and 5. Achievement of these goals therefore demands comprehensive approaches that focus on strengthening health delivery systems – including community health. CHWs help fight the top killers of mothers and children; build capacity to handle the growing burden of non-communicable diseases; and help prepare for and respond to health emergencies. Many countries – including Ethiopia, Nepal, and Brazil – have seen transformative results from strengthening their community health systems. In Liberia, CHWs played a critical role in responding to the Ebola crisis. This success has resulted in an increase in number of funders of and organisations working in community health. Recognising this potential, many global efforts are underway to strengthen community health systems. These include the One Million Community Health Workers Campaign and the Financing Alliance for Health. 1.1.1 Health Situation in Malawi Over the past three decades, Malawi has made great strides in improving key health indicators. Maternal mortality declined by one-third, from 957 to 634 deaths per 100,000 live births between 1990 and 2015 (WHO, 2015). The percentage of births delivered by a skilled attendant increased from 54.2 percent in 2000 to 89.8 percent in 2015 (National Statistical Office, 2016). Over the same period, stunting in children under five years of age declined from about half to just over a third, and the percentage of children sleeping under a mosquito net increased from 7.6 to 44.7 percent (NSO, 2016). Most notably, Malawi reached Millennium Development Goal 4, achieving a 72 percent reduction in child mortality between 1990 and 2015, from 242 deaths per 1,000 live births to just 64 (World Bank, 2016). These successes may be linked to several factors. Adopting and scaling up evidence-based interventions, such as community-based distribution of family planning (FP) and integrated community case management (iCCM) for childhood illness, enabled more equitable access to essential health services. Also, expanded support to community health providers has filled gaps in health service delivery. However, despite Malawi’s health achievements, there is still a long way for Malawi to achieve access to quality health care especially in the rural communities. According to UNICEF (2014), seventy percent of all child deaths are due to preventable causes, including malaria, diarrhea, pneumonia, anemia, and malnutrition. The country’s neonatal mortality rate is among the highest in the world, with an estimated 27 deaths per 1,000 live births (NSO, 2016). Still, the country has laid important groundwork for reaching new national and global health targets, such as the Sustainable Development Goals and Family Planning 2020 commitments. 1.1.2 Malawi’s Health System Structure: Community Health Providers Help Improve Coverage Malawi’s Ministry of Health (MOH) determines the direction of the country’s health and development sector through national-level policy guidance. In 1998, the Government of Malawi (GOM) designated greater political and administrative authority to the district level, with district councils and the district health office (DHO) overseeing planning, implementation, and coordination of health activities, including at the community level, often with the support of nongovernmental organizations, other private sector organizations, and civil society. The health system comprises primary, secondary, and tertiary levels of care linked through a referral system. Most Malawians access health services at the primary level. Both the public and private sectors play crucial roles in delivering health services. Today, Malawi has approximately 10,000 health surveillance agents (HSAs) deployed in communities across the country, comprising one-third of the health workforce (Smith, et al., 2014). HSAs have been active since the 1950s when they provided immunizations and in 1998, HSAs were integrated into the formal health system (Callaghan-Koru, 2012). Each HSA is linked to a primary-level health facility but also delivers a range of services in communities in accordance with the country’s Essential Health Package (EHP). These services include information on hygiene and sanitation; immunizations; growth monitoring; antenatal and postnatal care education; nutrition counseling; FP; disease surveillance; HIV testing and counseling; iCCM; and other basic curative health services (Government of Malawi, 2009). For decades, Malawi has recognized the importance of community health providers in expanding health service coverage, responding to emergencies, and reaching hard-to-access populations. The country has slowly increased the number of HSA responsibilities over time and has also increased support to HSAs to help guarantee positive health outcomes. In 1998, the GOM made a strategic decision to formalize HSAs as part of the country’s health workforce and pay them salaries to support their effectiveness. A decade later, Malawi was still among a handful of countries in sub-Saharan Africa that paid community health providers a salary (George, 2012), which has become a practice of increasing popularity as countries have made efforts to standardize and bolster support to community health providers (WHO, 2015). The institutionalization of HSAs has provided Malawi with a large and experienced community health workforce that is quick to mobilize to deliver key interventions. One study showed that HSAs were satisfied with their status as salaried, government employees, citing it as a motivator and accountability mechanism (African Strategies for Health. 2015). However, at the same time, some studies suggest that a number of setbacks common in resource-constrained settings threaten their motivation and performance. These include inconsistent payments, lack of a guaranteed pension plan, perceptions that salaries are too low, poor supervision, heavy workloads, no or unclear opportunities for refresher trainings and career advancement, and a desire for salary to be linked to merit rather than just position (Kok & Muula, 2013; Chikaphupha, et al., 2016). 1.1.3 Community Health in Malawi In Malawi, community health refers to the provision of basic health services in rural and urban communities with the participation of people who live there. Formal community health workers (CHWs) have existed in Malawi since the 1970s, when Malawi established Cholera Assistants following an outbreak of cholera. The MoH later changed the cadre of Cholera Assistants to Health Surveillance Assistants (HSAs), with their job description focusing more on prevention and promotion services than curative services. However, the MoH has relied heavily on task shifting to HSAs as one way of addressing human resource gaps and promoting equity in access to health services. Therefore, many HSAs have taken on more tasks and curative services without adequate supportive supervision. Today there are several cadres of CHWs employed by the government, including: HSAs, Senior HSAs (SHSAs), Community Health Nurses (CHNs), Community Midwife Assistants (CMA), and Assistant Environmental Health Officers (AEHOs). HSAs and SHSAs alone make up over half of the MoH’s+17,000 health workers and continue to play a fundamental role in extending access to healthcare to all people in Malawi. Malawi also has an active network of Community Health Volunteers (CHVs). Community health is essential in improving health and livelihoods. 84% of the population lives in rural areas, 24% do not live within five kilometres of a health facility, and only 4% of rural households have access to electricity. Fifty six percent (56%) of Malawian adult women cite distance to health facility as a key barrier to health access when they are sick (NSO, 2016). Community health therefore connects millions of people to the health system. Moreover, community-level interventions are critical in fighting the top four leading causes of illness – HIV/AIDS, lower respiratory infections, malaria, and diarrheal diseases (Institute for Health Metrics and Evaluation, 2015). For example, integrated community case management (iCCM) programmes in Malawi rely exclusively on HSAs; HSAs often conduct immunisations; and HSAs can test for HIV. Going forward, CHNs will be able to distribute ARVs and actively monitor HIV patients. Community health also saves money: one study in Malawi found that community-based management of acute malnutrition is more cost-effective than facility care (Health Policy Planning, 2018). Overall, delivery of many life-saving health services would not be possible without Malawi’s strong network of CHWs. Although community health activities have underpinned many historical improvements in Malawi’s health outcomes, further progress is needed. Despite recent improvements in infant and under five mortality, household sanitation practices, and malaria case fatality rates, many community health challenges remain. For example, the maternal mortality rate of 439 deaths per 100,000 live births8 is significantly higher than the SDG goal of 70 per 100,000 live births; immunisation rates for children aged 12-23 declined from 81% to 76% between 2010 and 2015; and only 43% of children sleep under insecticide-treated mosquito nets (NSO, 2016). Moreover, the community health system continues to face significant resource constraints and inconsistencies around quality of services. Notably, Malawi needs 7000+ more HSAs to meet the Malawi policy recommendation of 1 HSA per 1000 people, and only 51% of current HSAs reside in their catchment areas. Improving health in Malawi hinges on addressing these challenges. 1.1.4 Community health Service delivery in Malawi The provision of basic health services in rural and urban communities with the participation of people who live there – is essential to improving health and livelihoods in Malawi. Community health activities have contributed to historical improvements in Malawi’s health outcomes, especially for women and children, such as the decline in child mortality and malaria fatality rates. It is envisioned that community health will help Malawi to achieve its commitment to the Sustainable Development Goals (SDG); in particular, SDG 3 on universal health coverage. Therefore, building a strong community health system is core to Malawi’s development agenda. Malawi’s community health system faces resource constraints and inconsistencies around quality of service – which negatively affect health outcomes. Malawi has a shortage of at least 7,000 community health workers (CHWs), and existing CHWs are unevenly distributed across the country. Community health workers also face challenges related to lack of clarity on their roles and tasks, inadequate training and supervision, and limited access to transport. Communities experience frequent stock-outs of medicines and lack sufficient infrastructure (e.g., health delivery structures). Moreover, planning and implementation gaps are common due to ongoing challenges with decentralisation; inadequate institutional coordination, especially between government and partners; fragmented data collection; and lack of sustained community engagement. These challenges contribute to adverse health outcomes across the country; for example, life expectancy remains low at 47 years and the maternal mortality rate is high at 439 per 100,000 live births. Recognising the importance of community health and the opportunity to address these challenges, the Ministry of Health (MoH) developed the country’s first National Community Health Strategy (NCHS) for the period of 2017-2022. The NCHS ties into the Health Sector Strategic Plan (HSSP II), which underscores primary health care and community participation as core principles. The vision of the NCHS is to improve the livelihoods of all people in Malawi. The mission is to ensure quality, integrated community health services are affordable, culturally acceptable, scientifically appropriate, and accessible to every household through community participation – in order to promote health and contribute to the socio-economic status of all people in Malawi. By 2022, the NCHS aimed to contribute to achievement of two health outcome targets aligned with the HSSP II: a 25% decrease in the under-five mortality rate (U5MR) from 64 to 48 per 1,000 live births and a 20% reduction in the maternal mortality ratio (MMR) from 439 to 350 per 100,000 live births. To achieve these goals, the NCHS defined a new community health system for Malawi. Within this system, community health refers to a package of basic preventive, promotive, curative, rehabilitative, and surveillance health services delivered at the community level with the participation and ownership of rural and urban communities. This package consists of the community components of the Essential Health Package (EHP), as defined by HSSP II, and CHWs will deliver these services through an integrated approach. For the NCHS, integration is defined as the coordinated delivery of multiple health interventions as well as interventions from other sectors that improve health outcomes. Integration will take place at the point of care, which helps to improve health system efficiencies, reduce fragmentation, and increase access to care. Other key features within the community health system include a team-based structure for CHWs, strengthened supervision, reinforced community structures (e.g., Village Health Committee, Community Health Action Group), and enhanced coordination led by the CHS Section and district-level Community Health Officers. Overall, the NCHS outlined the aspirations for how the community health system should function and puts in place processes and activities to achieve these goals. The NCHS also had set six strategic objectives for the community health system – each with an ambitious target and interventions to implement by 2022: First is health services delivery: Deliver the Essential Health Package at community level through integrated services provided by CHWs in Community Health Teams (CHTs). Key interventions to achieve this goal include scaling up integrated delivery of the EHP at community level and rolling out CHTs with clear job descriptions for all CHW cadres. The target for 2022 is that 75% of HSAs deliver the majority of the community components of the EHP. Second is human resources: Build a sufficient, equitably distributed, well-trained community health workforce. Key interventions to achieve this goal include recruiting additional CHWs; promoting equitable geographical distribution of CHWs; and providing high-quality, integrated pre-service and in-service training to all CHWs. The target for 2022 is that Malawi reaches 74% of its policy recommendation for the ratio of trained HSAs to members of the population (~15K HSAs and ~1.5K SHSAs) and that 75% of HSAs and SHSAs are residing in their catchment areas. Third is information, communication, and technology: Promote a harmonised community health information system with a multi-directional flow of data and knowledge. Key interventions to achieve this goal include harmonising data management practices; exploring integrated mHealth solutions for CHWs; training all CHWs in the CHT on ICT and data management; and launching two-way feedback and data review systems between communities and the health system. The target for 2022 is that 75% of HSAs are reporting using the standardized village health register and that 50% of CHTs are using mHealth for integrated service delivery, data collection, and supervision. Fourth if supply chain and infrastructure: Provide sufficient supplies, transport, and infrastructure for CHWs in the CHT. Key interventions to achieve this goal include construction of Health Posts (Integrated Community Health Service Delivery Structures) and CHW housing units in hard-to-reach areas; procurement and distribution of durable, high-quality bicycles and motorcycles to CHWs; and scale-up of electronic supply and drug management to cover all of community health. The 2022 target is that 95% of HSAs have a high quality, durable bicycle and that 900 Health Posts are operational and supporting integrated community health service delivery in hard to reach areas. Fifth is community engagement: Strengthen community engagement in and ownership of community health. Key interventions to achieve this include generating support for community health (e.g., launching national community health day); building the capacity of prioritised community structures (e.g., VHCs, CHAGs, and HCACs), and rolling out enhanced social accountability mechanisms at community level (e.g., scorecards).The 2022 target is that 70% of Village Health Committees (VHCs) are meeting regularly on a monthly basis to support community health activities and that 70% of CHAGs and HCACs are active. Sixth is leadership and coordination: Ensure sufficient policy support and funding for community health and that community health activities are implemented and coordinated at all levels. Key interventions to achieve this goal include scaling up the coordinating function of the CHS Section at the national level; recruiting a Community Health Officer for each district; strengthening community-level coordination through CHAGs and CHTs; and hosting regular coordination meetings between stakeholders at all levels. The target for 2022 is that community health actors will have completed 80% of all agreed-upon coordination activities and milestones. 1.1.5 Health workforce challenges An estimated 57 countries are facing health workforce shortages and more than four million health workers are needed to fill this gap (Global Health Workforce Alliance and World Health Organization [WHO] 2010). The shortage of human resources for health and the double burden of infectious and chronic diseases cause greater mortality and morbidity, hamper the achievement of the health-related Millennium Development Goals, and impede economic growth in low- and middle-income countries. As a result, there is renewed international interest in the potential for CHWs to take on an expanded role in strengthening health system responses. CHWs are community-level practitioners, often selected from among community members, who provide basic health and medical care to residents with a special focus on preventive services. CHWs generally function as the first point of care for communities and often interact with their communities at the household level (The Earth Institute 2011), unlike doctors and nurses who are formally educated health practitioners, situated in clinics or hospitals. CHWs also work with much less training and significantly less pay than doctors and nurses. Many countries developed national programs of CHWs following the Alma-Ata Declaration on primary health care in 1978.1 CHWs are widely employed throughout Africa and Asia and, to a lesser extent, in South America, as well as in higher-income countries such as the United States and the United Kingdom. CHWs around the globe have been deployed to provide a variety of services with a general focus on nutritional interventions, maternal and child health promotion, childhood immunization, infectious disease control and non-communicable disease interventions (Global Health Workforce Alliance and WHO, 2010). The WHO asserts that increasing the role of CHWs is appropriate in settings that have a high disease burden and shortage of health workers. In this regard, CHWs can fill the human resources gap and effectively supply essential health services (WHO 2008). Several existing systematic (Lewin et al. 2010) and non-systematic reviews (Haines et al. 2007; Sanders and Lehmann 2007) demonstrate that CHW interventions are effective against malaria (Christopher et al. 2011), and that CHWs can increase immunization coverage and improve breastfeeding rates, tuberculosis (TB) treatment and neonatal survival (Bang et al. 2005). Less is known about the effectiveness of CHW programs in preventing child deaths from pneumonia or diarrhea (Bryce et al. 2005). Malawi is a low-income country with a critical shortage of health workers (one doctor per 100,000 people) and a high disease burden (WHO, 2008). Life expectancy at birth is 47 years and the infant mortality rate is 92 deaths per 1,000 live births. HIV prevalence is 11 percent in adults aged 15 to 49, and TB prevalence is 174 per 100,000 people (WHO, 2012). Throughout Malawi, CHWs (known as HSAs) are critical to the overall health system, playing a vital role by connecting the community with the formal healthcare sector. The Malawi Ministry of Health (MMOH) considers that the primary role of the HSA is to provide essential health care at the community level to improve the health status of all Malawians, thus improving productivity and ultimately national economic growth (MMOH, 2012). The MMOH states that the three primary roles of the HSA are to: provide health promotion, disease prevention and curative care; promote community participation in health-care activities; and provide surveillance of health problems in the community. HSAs currently comprise 30 percent of the health workforce in Malawi and they are often the only health workers serving rural communities (MMOH, 2010). HSAs have primary responsibility for the delivery of several health services, particularly child immunization. The MMOH aims to have HSAs responsible for further prevention work such as recognizing, treating and referring pneumonia cases, yet the MMOH recognizes that HSAs may be ill equipped, in terms of training and resources, to do so (Carlson et al., 2008). 1.2 Problem Statement Health Surveillance Assistants (HSAs) are grass root health care providers in Malawi. They spearhead provision of community essential health package (c-EHP). HSAs play an important role in connecting communities with the formal health care sector. Malawi is one of the countries with high immunization coverage due to the HSA’s door to door immunisation efforts for all important vaccines. During national campaigns such as mass Polio vaccination campaign, Cholera, Typhoid and Covid-19 vaccination campaigns among others, HSAs have been the frontline cadres to deliver the vaccines to the masses. In addition to this, HSAs have also been working on nutrition screening and treatment for infants, conducting under five clinics in communities and at facility level, administering family planning methods except norplant. HSAs were formerly recruited as temporary Smallpox Vaccinators’ in the 1960’s and later as `Cholera Assistants’ in the mid-1970's. Currently, the HSAs are on Malawi Government’s payroll under the Ministry of Health (MoH) and they are officially being referred to as Disease Control and Surveillance Assistants. This cadre has contributed greatly to the delivery of preventive health services in rural areas of Malawi since their initial recruitment and establishment in the government system. Entry requirement for an HSA is a Malawi School Certificate of Education (MSCE) and mostly those that did not qualify to university. They enter the government system on grade M (a junior civil service position). They are only promoted once in their career path as an HSA to Grade L (Senior HSA). From this position, if they do not upgrade to another career path such as nursing or public health among others according to choice, they are never promoted until they retire. No further staff development is provided. This is unlike other civil servants, for instance, primary school teachers who have risen up the ranks to university lectures and senior officers at the ministry headquarters. Yet the HSAs are always overburdened with work by government and Civil Society Organisations working in communities. The National Community Health Strategy (NCHS) of 2017 to 2022 indicates that Malawi’s HSAs receive inadequate training to effectively provide all community essential health packages. HSAs face numerous challenges related to training, as well as challenges in defining their roles and those of their supervisors, and setting priority tasks by HSAs, their supervisors and policy makers. Community health activities have contributed to historical improvements in Malawi’s health outcomes, especially for women and children, such as the decline in child mortality and malaria fatality rates. Going forward, community health will help Malawi to achieve its commitment to Sustainable Development Goals (SDGs). Therefore, building a strong community health system is core to Malawi’s development agenda (NCHS, 2017). Evidence from various countries shows that CHWs can effectively deliver key health interventions (Lewis, et al., 2010). Given the ongoing health and community workers human resources shortage in Malawi, HSAs will remain an essential cadre in driving forward efforts to achieve universal health coverage and it is important to better understand their role, their training capacity, their training needs and how they cope with magnitude of work. 1.3 Objectives The main objective of the study is to investigate the role of Health Surveillance Assistants in promoting preventive health in Mulanje District. 1.3.2 Specific Research Objectives i. To identify the roles of Health Surveillance Assistants in community health work. ii. To explore the workload for health Surveillance Assistants. iii. To explore the training capacity of health Surveillance assistants as community health workers iv. To examine the capacity challenges faced by HSAs in executing their community health work. v. To analyse the measures used by HSAs to cope with the magnitude of work as community health workers. 1.4 Research Questions i. What are the roles of Health Surveillance Assistants in community health work? ii. What is the workload for health Surveillance Assistants? iii. What is the training capacity of health Surveillance assistants as community health workers? iv. What are the capacity challenges faced by HSAs in executing their community health work? v. What measures are used by HSAs to cope with the magnitude of work as community health workers? 2.0 Literature Review 2.1.1 Competence Motivation Theory Competence motivation theory is a conceptual framework designed to explain individuals’ motivation to participate, persist, and work hard in any particular achievement context. The theory applies to this study as helps in understanding the magnitude of HSAs work in Malawi and how they persist such work pressure to achieve results in a work environment full of challenges and amidst limited 12-weeks training given to the HSAs. Harter’s competence motivation theory (1978) can be used to explain motivation to participate and withdraw. This theory represents an interactionist view of behavior, incorporating both individual and situational factors that impact one’s motivation. The original model came from White (1959). Harter (1978) expanded on the premise that people are intrinsically motivated to master specific domains. As a consequence, they gain and display competence and control over their environment, which in turn increases pleasure (positive affect or enjoyment). If people succeed, it increases motivation to adhere to physical activity. However, if people do not believe they are competent in that domain, they will have negative affect, and this will decrease their motivation. In addition, her model incorporates the impact of significant others on one’s perceptions of competence, affect, and motivation (Harter, 1978). According to Harter (1978), people are intrinsically motivated to master a domain that is challenging. If they are successful and they are supported, given approval, and positively reinforced by significant others, their perceptions of competence and control will increase. This will enhance intrinsic pleasure (or positive affect), which in turn increases motivation to continue to master that domain. However, if people are unsuccessful at challenges and/or they are not supported by significant others, their perceptions of competence and control will decrease. As a result, intrinsic pleasure will be low, which will reduce motivation to continue participation in that area. Different activities will not produce the same outcomes in terms of cognitions, affects, and behaviors (Weiss & Ferrer-Caja, 2002). People do not need to display competence in all domains to experience positive affect. Community health workers are public health workers (Nayana, 2023). Their goal is to connect communities with their health care systems and state health departments. Community health worker (CHW) is an umbrella term that includes a range of community health aides. They are typically citizens of the community they serve and support the health system as a volunteer or paid aide. Community health workers go through a much shorter training period than professional workers. They are trained to support one or multiple functions of health care — sometimes from a national certification authority. However, community health workers do not include formally trained nurses, medical assistants, physician assistants, emergency medical technicians (EMT) professionals, or health professionals. Rather, community health workers are community advocates and are often agents of social change. Because of this, it is important that community health workers understand and respond to the social and cultural norms of the communities they serve — and almost all CHWs serve their own community. 2.2 Who are community health workers? Community health workers are public health workers (Ambardekar, 2023). Their goal is to connect communities with their health care systems and state health departments. Community health worker (CHW) is an umbrella term that includes a range of community health aides. They are typically citizens of the community they serve and support the health system as a volunteer or paid aide. Community health workers go through a much shorter training period than professional workers. They are trained to support one or multiple functions of health care — sometimes from a national certification authority. However, community health workers do not include formally trained nurses, medical assistants, physician assistants, emergency medical technicians (EMT) professionals, or health professionals. Rather, community health workers are community advocates and are often agents of social change. Because of this, it is important that community health workers understand and respond to the social and cultural norms of the communities they serve — and almost all CHWs serve their own community. Community health workers provide support to local healthcare organizations and systems through various tasks, depending on what type of community they are serving (Ambardekar, 2023). Community health worker duties include: home visits, sanitation of the environment, provision of water and nutrition, first aid, treatment of simple or common illnesses, health education, maternal and child health support, family planning activities, tuberculosis (TB) or HIV and AIDS care, communicable disease control, community development activities, and recordkeeping and collection of data. Community health workers perform these tasks in a wide range of breadth and depth, depending on the education and training of the CHW and the health needs of the community. Community health workers hold a unique and important role within the healthcare community. In both urban and rural environments, community health care workers usually share life experiences, socioeconomic status, language, and ethnicity with the members of the community they serve (Ambardekar, 2023). CHWs may serve in many positions within their community, such as: community health advisors, health advocates, outreach educators, community health representatives, and peer health educators. Within these roles, community health workers may offer translation services, provide culturally relevant health education, or provide informal counseling and guidance. Ultimately, community health workers have a unique opportunity to reach community members where they live, eat, work, and more (Ambardekar, 2023). This leads to improved access to health care services, increased health screenings, stronger connections between community members and healthcare systems, improved communication between communities and health providers, reduced need for emergency services, and improved community health. Community health workers can also function as role models by promoting, encouraging, and supporting positive and healthy self-care and self-management behaviors among community members. As advocates, they can help ensure that underserved community members get the services and follow-up care they need. Research shows that successful community health workers can help reduce racial and ethnic disparities in health care and build strong communication with existing health care systems. Currently, there is no national standard for community health worker education, training, or certification. However, most community health workers undergo on-the-job training that is specialized to their specific program. There is a wide range of training programs. Some may cover only the skills required for a singular project, while others may be more comprehensive. Many modern training programs are offered by academic institutions and community-centered organizations. No matter where training is offered, the goal is to meet the needs of a broad scope of CHW employers and develop the skills and knowledge of the community health workers who train there. Some cities and states have developed standardized training programs and curriculum, some of which work with colleges and universities (Ambardekar, 2023). 2.3 Roles and Responsibilities of CHWs The existing literature shows a wide diversity of roles and responsibilities for CHWs. Published programs have required that CHWs provide health education, serve as role models and community advocates, increase access to healthcare resources, and collect data for research purposes (Rhodes, et al., 2007). The Community Health Worker National Workforce Study, conducted by the Health Resources and Services Administration (HRSA), grouped CHW roles into the following five categories: member of care delivery team; navigator; screening and health education provider; outreach-enrolling-informing agent; and organizer (USDHHS, 2007. Similarly, the health targets for CHW programs are diverse, including cardiovascular disease, diabetes, asthma, maternal/child health, cancer screening, and general health promotion. Integrating CHWs into a program increases job opportunities for people who have experienced homelessness. The CHW profession is a platform for vulnerable populations to gain work experience, professional skills, and personal development. Once in the field, CHWs may find opportunities to transition to social work, nursing, and a number of other health related professions. Two CHWs who participated in the National HCH Council’s project went on to pursue advanced degrees in medicine and social work. Employing CHWs not only provides jobs to community members but builds skills and opportunities in CHWS for future employment; ultimately this strengthens the community as a whole (Sinai Urban Health Institute, 2014). In a national workforce study of community health workers, most organizations reported that they made the decision to hire CHWs because they learned about their successful utilization, believed they were cost effective, and their programs were more effective when using one-on-one outreach by CHWs (Health Resources and Services Administration, 2007). Part of what makes a CHW such an effective member of a health care delivery team is the flexibility and diversity of what they can do within the clinic and in the community. There is a wide range of activities, tasks, and responsibilities a CHW can take on in the HCH setting. The primary responsibilities of any CHW working in the HCH setting are to build trusting relationships with clients and to connect those clients to care, eliminating barriers and advocating for systemic changes along the way. The effectiveness of CHWs lies in their ability to gain access to hard to reach individuals and to patiently coach and support them as they work towards health care goals (Health Resources and Services Administration, 2007). According to Rural Health Information Hub (2016), the role of the CHW includes the following: Firstly, they create connections between vulnerable populations and the health care system. CHWs in HCH programs work to guide patients experiencing homelessness toward more permanent primary care services outside the hospital system. Establishing a secure, trusted connection with a primary care provider can help prevent persons experiencing homelessness from reliance on Emergency Departments to meet primary care needs. Secondly, CHWs provide care coordination and care transitions for clients. The mobility of CHWs within their communities creates opportunities for more coordinated care. CHWs can serve as a liaison between multiple services and help with care coordination and care transitions for their clients. In the process of connecting clients with multiple services, CHWs build relationships with local agencies, advocating for their clients in the process. The more CHWs are involved in the community at large, the more effective the linkages between the community and the health care system become (Rural Health Information Hub, 2007). Thirdly, CHWs assist clients with enrollment in programs and benefits for which they are eligible. In addition to connecting clients with health care services, CHWs work to connect clients with various social service programs for which they may be eligible. These programs and benefits can range from enrollment into SSI/SSDI to enrollment into a GED program. Fourthly, CHWs encourage cultural competence among health care professionals serving vulnerable populations. CHWs’ lived experience of homelessness helps them build rapport with clients while also informing policies, procedures, and practices within the HCH clinic. CHWs have a unique insight into the perspectives of their clients which helps them identify barriers or unmet needs within the HCH clinic that may go unnoticed by HCH clinicians or administrators. Fifthly they advocate for vulnerable populations within the health care system and the community at large. CHWs amplify the voices of the community within their HCH clinics thereby informing health professionals of the evolving needs and conditions of their target population. Additionally, they build capacity within the clinic and the community at large to address health issues. Staff at HCH clinics often operate with incredibly full workloads and are not able to meet all the needs of extremely high needs clients. Using CHWs to either support or expand existing services enables HCH programs to spend more time on their highest needs clients. 2.4 CHWs workload challenges Community health workers (CHWs) play an important role in improving access to health services to a broader population; particularly to communities living in remote areas. However, the productivity of CHWs is affected by the workload they have. We aimed to summarize and present CHWs’ perceived workload in low-and middle-income countries (LMICs). In many low- and middle- income countries (LMICs), primary health care approach is adopted through the deployment of community health workers (CHWs) (WHO, 2013). Since the Alma-Ata Declaration, a well-designed CHWs approach within the primary health care system has been considered to be an effective strategy for achieving universal health coverage (UHC). Systematic reviews in different settings also reported the effectiveness of CHWs in providing a range of promotive, preventive and basic curative health services (Lewin, et al., 2010; Glenton, et al., 2011; Gilmore & McAuliffe, 2013; Mwai , et al., 2013; Lassi, et al., 2016). As task-shifting strategies become widely implemented in many countries, CHWs are assigned for additional tasks through in-service trainings. As a result, the health services provided by CHWs are evolving through time with a wider scope and complexity (Jaskiewicz, 2012; Frymus, et al., 2015) which could, in turn, reduce the level of productivity and increase the risks of turn over intention(Kimbugwe, et al., 2014). Higher workload among rural health workers has also been associated with increased level of burnout (Dugani, et al., 2018). Community health workers’ productivity is largely determined by the level of manageable workload in terms of tasks (Jaskiewicz, 2012). However, despite the growing recognition of CHWs’ critical role in increasing access to health services for underserved communities, little attention has been given to how much work responsibility can CHWs take before a work overload negatively affects their productivity. A recent review by WHO on CHW programs highlights that the tasks assigned to CHWs need to align with the level of training and appropriate remuneration and that attention should be given to the views of CHWs in terms of their work responsibilities (WHO, 2020). Community health worker workload is a multifactorial concept that can be described by the interplay of the number and organization of tasks and the catchment area (number of households and their geographic distribution (Jaskiewicz, 2012). This systematic review will present the views of CHWs on their perceived workload, in terms of the specific subcomponent of workload that is mostly contributing for their workload. The findings could inform program managers to design task-shifting strategies that ensure realistic workload and contribute for productive CHWs and sustainable CHW programs. The definition of CHWs varies across countries and programs. For the purpose of this review CHWs are defined as health workers based in communities (i.e. conducting outreach from their homes and beyond primary health care facilities or based at peripheral health posts that are not staffed by doctors or nurses), who are either paid or volunteer, who are not professionals, and who have fewer than 2 years training but at least some training, if only for a few hours (WHO, 2022). Community health workers in most of the reviewed articles reported that they are required to perform a very broad-range of tasks ranging from multiple health programs to agricultural and political sectors. While there is no known fair/ideal number of tasks that would be manageable by CHWs, too many roles could have a negative impact on level of productivity (Jaskiewicz, 2012). It was further noted in the reviewed articles that CHWs perform tasks that are not described in their job descriptions and sometimes perform tasks that they are not trained for or do not have the required knowledge and skill. Reports show that when CHWs are overwhelmed by a broad-range of tasks, they tend to select few that they prefer to do and ignore the others (Hermann, 2009), which could in turn, affect the overall success of the CHW program. A recent review by WHO working group also emphasizes the importance of clearly defined tasks that align with the appropriate renumeration and support (WHO, 2022). On the other hand, how well the tasks are organized or integrated is crucial. Even though the number of tasks is high, integrating the timing and approach of implementation may decrease workload and increase productivity (Jaskiewicz, 2012). Lack of transport was the other common subcomponent of workload which was reported by the reviewed articles. Most of the CHWs in these articles reported a feeling of exhaustion to perform their duties after walking for long hours to cover their target households. The design of community health programs in several countries has been mainly focused on the amount of time that would be required to finish a given task, and less attention has been given to the effect of time spent to access the target households on productivity. Although we found limited data on the link between transport availability and productivity, it appears that lack of attention to travel time and lack of transport to access the households is a key factor for the productivity of CHWs. Furthermore, a combined effect of lack of transport and number of households might have implications on productivity. The literature review shows that perceived workload among paid and volunteer CHWs was comparable; both groups of CHWs reported that they have high workload. However, looking at the subcomponents of workload, competing socio-cultural and economic demands was an important element to volunteer CHWs than paid CHWs. Unlike the paid CHWs, unpaid volunteer CHWs cited that they are also expected to do income generating activities to support their families. As such, expecting volunteer CHWs to work for many hours per week creates extra burden, which would eventually lead them to leave their responsibility (Perry & Freeman, 2009). In some situations, volunteer CHWs have out of pocket expenditures for a work-related activity that led them to get poorer after joining the volunteer work (Schurer, 2020). The literature review shows that for many CHWs, their workload is overwhelming. In addition to the increasing number of tasks that the CHWs are expected to perform, lack of transport further intensified their workload. While acknowledging the benefit of decentralization and task shifting strategy to increase access to health services to remote areas, program managers need to make a careful consideration as to how the additional tasks can be well integrated into the existing responsibilities of CHWs. It is also critical that when workload of CHWs is investigated all the integral components of workload (number of tasks, catchment area/number of households, and availability of transport) need to be considered and not solely on the number of tasks per CHW. 2.5 Health Surveillance Assistants: Duties and Responsibilities Health Surveillance Assistant (HSA) are Primary Health Care workers serving as a link between a Health Facility and the community. HSAs are training social and community health workers responsible for the following: Motivating, informing and assisting individuals, families and communities in the promotion and maintenance of personal and environmental health; Detecting potential and real health hazards in the community and referring them appropriately to a health facility; Detecting and reporting disease outbreaks; Working directly with village and community leaders to identify and forming community support groups such as health committees, volunteers, and other local service providers; and Collaborating with Health Facility workers. The HSAs undergo a 12 weeks training to acquire appropriate knowledge, attitudes and skills in maternal and neonatal health care at the community level. The duties of HSAs are categories into five areas: (1) Community health, (2) family health, (3) environmental health, (4) prevention and control of common community diseases, and (5) management and administration. According HSA Training Facilitator Guide (2009), after undergoing the training a Health Surveillance Assistant should be able to do the following under community health: Conduct community assessment and village inspection within the assigned catchment area; Identify community health needs within the assigned catchment area; Conduct disease surveillance within the assigned catchment area; Respond appropriately on disease outbreaks; Facilitate the formation of village health committees and other support groups; Supervise village health committees and other community home based health care activities; Encourage community participation in village health activities; and Report any health problems identified within the community. On family health, HSAs are responsible for the following: Promote proper care of pregnant women before, during and after delivery; Educate families on family planning methods; Conduct child growth monitoring activities; Conduct immunization activities; Advise the community on proper nutritional practices; Educate the community on key care practices for accelerated child survival and development of the under-five children; Promote the elimination of harmful reproductive health practices; and Provide guidance to the youth through youth friendly health services. On environmental health, the duties of HSAs are: Facilitate the promotion of environmental hygiene and sanitation; Facilitate the provision of safe water supply; Educate families and communities on proper food hygiene practices; Inspect public facilities in accordance with the Public Health Act for maintenance of hygiene; and Apply recommended insecticides to prevent and control vectors and vermin at the household level. on the prevention and control of common community diseases, HSAs do the following: Conduct health education to families and the community on the prevention and control of common occurring community diseases; Conduct village clinics for treatment of minor ailments; Refer severe cases to the nearest health facility for proper treatment; and Conduct patient and clients follow-up within the assigned catchment area The HSAs also perform management and administration duties namely: Write monthly plans and reports; Record data collected in relevant registers; Observe the Malawi Public Service Regulations as they perform their duties; and Maintain equipment utilized on the job. 2.6 HSAs as Key Community Health Workers in Malawi In many countries, community health workers (CHWs) are a key component of strategies to achieve universal health coverage, through extension of primary health services to underserved communities at low costs in contexts of chronic financial and human resource shortages (Tulenko, et al., 2013). In Malawi, a large number of different types of CHWs link communities with the health sector (Nyirenda, et al., 2014). The largest group is the government paid cadre of health surveillance assistants (HSAs), comprising 30 % of the health workforce (Smith, et al., 2014) and totalling 9,137 (Ministry of Health). HSAs are recruited by the government, must have secondary school level education and receive 12 weeks training (Nsona, et al., 2012). Once employed, they are supposed to reside in their catchment area, working mainly in health promotion and prevention for a population of about 1,000 (Gilroy, et al., 2012). From 2008, HSAs’ curative tasks have been expanded. HSAs working in hard-to-reach areas conduct integrated community case management of childhood illnesses (iCCM) (Nsona, et al., 2012). HSAs are supervised by senior HSAs or (assistant) environmental health officers (Callaghan-Koru, et al., 201. They are attached to a hospital or health centre, but are supposed to spend most of their time in the community. HSAs are supported by village health committees (VHCs), consisting of ten unpaid village representatives elected by the community, and other volunteers, such as members of HIV support groups and traditional birth attendants (Kok & Muula, 2013). Evidence from various countries shows that CHWs can effectively deliver key health interventions (Lewin, et al., 2010). Although large scale studies on effectiveness of HSAs in Malawi are missing, evidence on HSAs’ positive effect on immunization rates and access to anti-retroviral treatment for HIV is available (Bemelmans, et al., 2010). Given the ongoing human resources shortage in Malawi, HSAs will remain an essential cadre in driving forward efforts to achieve universal health coverage and it is important to better understand which factors influence their performance. Earlier studies identified several constraints to HSAs’ motivation and job satisfaction, which were negatively influencing performance. Factors related to the health sector, such as lack of supplies and infrastructure (Callaghan-Koru, et al., 2012). unclear or too many roles and responsibilities and inadequate human resource management related to training, supervision, incentives and career development have all been identified. Factors related to the community were (less often) identified: inadequate support from community volunteers and unrealistic expectations from the community regarding HSAs’ roles could hamper HSAs’ work (Martiniuk, et al., 2014). In Malawi, earlier research revealed constraints regarding HSAs’ interpersonal relationships with actors in the health sector related to inadequate supervision and communication, leading to demotivation (Puchalski-Ritchie, et al., 2012) and mistrust because of problems in drug supply and inadequate support mechanisms for HSAs conducting iCCM in hard-to-reach areas. Improved communication between HSAs and the health sector via mobile phones was reported to increase self-confidence of HSAs and community trust (Campbell, et al., 2014). Thus far, an in-depth assessment of the role and magnitude of HSAs as community health workers is not properly documented. This study investigated the role of Health Surveillance Assistants in promoting preventive health in Mulanje District, in order to inform policy and practice on optimizing HSA performance. 2.7 Research Gap In Malawi, earlier research revealed constraints regarding HSAs’ interpersonal relationships with actors in the health sector related to inadequate supervision and communication, leading to demotivation (Puchalski-Ritchie, et al., 2012) and mistrust because of problems in drug supply and inadequate support mechanisms for HSAs conducting iCCM in hard-to-reach areas. Thus far, an in-depth assessment of the role and workload of HSAs as community health workers is not properly documented. This study investigated the role of Health Surveillance Assistants in promoting preventive health in Mulanje District, in order to inform policy and practice on optimizing HSA performance. 3. Methodology The study was conducted in Mulanje district of Southern Malawi. Mulanje is a distrcit in the Southern Region of Malawi, close to the border with Mozambique, to the east. The district covers an area of 2,056 sq. km. and has a population of 428,322. The district is dominated by people of Lomwe tribe. Mulanje lies along the M-2 highway from Thyolo to the west to the Mozambican border to the east. It is approximately 69 kilometres (43 mi), by road, south-east of Blantyre, the commercial and financial capital of Malawi. This is approximately 380 kilometres (236 mi), by road, southeast of Lilongwe, the largest city in Malawi and the country's capital. A study can be either qualitative or quantitative. However, a study can employ both qualitative and quantitative research approaches. This study used a mixed research design of qualitative and quantitative research designs. Specifically, the study got insights from exploratory and descriptive research designs. The population of this study is Health Surveillance Assistants in Mulanje District who are 420 (Mulanje DHO Data, 2023). The respondents were identified using purposive sampling by targeting HSAs and simple random sampling were used to identify the sample. This study targeted 59 HSAs from Mulanje district. The sample was arrived at using online sample calculator with 90 percent confidence level, 10 percent sampling error and 50 percent population proportion. The method of data collection to be used is interviews. Interviews are a method of data collection that involves two or more people exchanging information through a series of questions and answers. The questions were designed by the researcher to elicit information from interview participants on a specific topic or set of topics. The study used a questionnaire as a tool for data collection. The questionnaire had both closed ended and open ended questions that will provide the respondents with options or responses to choose from and space to write their responses respectively. The closed ended questions provided options that will range from yes or no and a likert scale of strongly agree, agree, neutral, disagree and strongly disagree. The questions were mapped from the specific objectives to ensure that the study addresses all objectives. The researcher has used statistical analysis to analyse the quantitative data. Thematic analysis has been used to analyse the qualitative data. The quantitative data has been analysed through descriptive statistics using Statistical Package for Social Sciences (SPSS). Descriptive statistics used include calculating the mean, variance and standard deviation, and use of tables, graphs and charts. Cross tabulations have been used to interpret the results alongside demographic variables of gender, age and number of years of working as an HSA. 4.3 Results 4.3.1 Objective 1: Roles of Health Surveillance Assistants in Community Health Work The first specific objective of the study was to identify the roles of Health Surveillance Assistants in community health work. Data for this objective was collected through using statements that focused on general roles of an HSA as per the Malawi Government Health Surveillance Assistants Training manual. The respondents were given statements to which they were to indicate Yes or No. The statements were I perform duties on community health, I perform duties on family health, I perform duties on environmental health, I perform duties on prevention and control of common community diseases, and I perform duties on management and administration. The frequencies show that all the respondents indicated ‘Yes’ that they perform duties on community health, family health, environmental health, and prevention and control of common community diseases. This is the case as these are core duties for every Health Surveillance Assistant which is also reflected in the HAS training manual and job description. On whether the HSAs perform duties on management and administration, 34 indicated ‘Yes’ representing 58 percent and 25 indicated ‘No’ representing 42 percent. This is the case for the management and administration duties as there is a ranking for HSAs and senior HSAs. The senior HSAs act as supervisors hence performing managerial and administrative duties. The results are presented in table 5 and figure Table 5: Roles of Health Surveillance Assistants in community health work SN Statement Yes No 1 I perform duties on community health 59 (100%) 0 (0%) 2 I perform duties on family health 59 (100%) 0 (0%) 3 I perform duties on environmental health 59 (100%) 0 (0%) 4 I perform duties on prevention and control of common community diseases 59 (100%) 0 (0%) 5 I perform duties on management and administration 34 (58%) 25 (42%) Figure 2: Roles performed by HSAs as community health workers 4.3.2 Objective 2: Workload for Health Surveillance Assistants The second objective of the study was to explore the workload for health surveillance assistants. The respondents were given statements on workload for HSAs from which they had to indicate the extent to which they agree or disagree with given statement. The following were the statements: our duties are too broad hence having a lot of work load; we serve too many people hence having a lot of work load; NGOs use us for community work hence increasing our workload; and there are few community health workers (HSAs) hence an increased work load. The frequency distribution of the responses suggests that there were varied responses. However, the responses are skewed on the strongly agree and agree which show that HSAs experience high workload challenges. On the first statement that HSA duties are too broad hence having a lot of work load, 35 strongly agreed representing 58 percent, 19 agreed representing 32 percent, 4 disagreed representing 7 percent and 2 strongly disagreed representing 3 percent. On the second statement that HSAs serve too many people hence having a lot of workload, 41 strongly agreed representing 69 percent, 6 agreed representing 10 percent, 8 respondents had a neutral view representing 15 percent, 2 disagreed representing 3 percent and another 2 strongly disagreed representing 2 percent. On the third statement that NGOs use HSAs for community work hence increasing our workload, 17 strongly agreed representing 28.5 percent, 17 agreed representing 28.5 percent, 8 had neutral view representing 15 percent, 15 disagreed representing 25 percent and 2 strongly disagreed representing 3 percent. On the fourth statement that there are few community health workers (HSAs) hence an increased work load, 39 strongly agreed representing 66 percent, 16 agreed representing 27 percent and 4 disagreed representing 7 percent. The results are presented in table 6 and figure 3 below. Table 6: Workload for Health Surveillance Assistants SN Statement Strongly Agree Agree Neutral Disagree Strongly Disagree 1 Our duties are too broad hence having a lot of work load 34 (58%) 19 (32%) 0 (0%) 4 (7%) 2 (3%) 2 We serve too many people hence having a lot of work load 41 (69%) 6 (10%) 8 (15%) 2 (3%) 2 (3%) 3 NGOs use us for community work hence increasing our workload 17 (28.5%) 17 (28.5%) 8 (15%) 15 (25%) 2 (3%) 4 There are few community health workers (HSAs) hence an increased work load 39 (66%) 16 (27%) 0 (0%) 4 (7%) 0 (0%) Figure 3: Workload for Health Surveillance Assistants Suggestions of how to address workload challenges faced by HSAs The respondents were asked to present suggestions on what can be done to address workload challenges faced by Health Surveillance Assistants. There were multiple suggestions. The first and most recurring suggestion was employing more HSAs. This is said to be a solution as it would reduce the HSA to community members’ ratio. Currently the workload is beyond the standard for a single HSA as community health worker. Here are some of the responses: “Government to increase more HSAs to reduce workload” “Employ more HSAs so that we should have a less population to serve” “Deploy more HSAs to reduce Workload” The second suggested solution was to provide reliable transport so as to ease transport problems as HSAs have to visit the people in their respective communities and households. The third solution to the workload challenge is to have more training for the effective work of HSAs. The trainings will make HSAs have adequate capacity to ease their work challenges as such adequate knowledge would ease their case management abilities there by helping communities within the available small time space. The fourth solution was to have new system (technology) on reporting activities so as reduce time spent on writing reports. An additional solution in extension to the reporting system is that HSAs should be provided with laptops for compiling information and executing their duties. 4.3.3 Objective 3: Training capacity of Health Surveillance Assistants as community health workers The third objective of the study was to explore the training capacity of health surveillance assistants as community health workers. The respondents were provided with statements from which they had to indicate the extent to which they agree or disagree with the given statement. The following were the statements: The training time for HSA Course is in adequate; The training covers too much content; The training does not offer adequate knowledge and skills; and The training does not provide for adequate practical for hands on experience. There were varied responses as per the frequency distribution on the statements. On the first statements that the training time for HSA Course is in adequate, 48 out of 59 respondents strongly agreed representing 82 percent, 2 agreed representing 3 percent and 9 strongly disagreed representing 15 percent. On the second statement that the training covers too much content, 34 strongly agreed representing 58 percent, 9 agreed representing 15 percent, 5 had a neutral view representing 8 percent, 7 disagreed representing 12 percent and 4 strongly disagreed representing 7 percent. On the third statement that the training does not offer adequate knowledge and skills, 18 strongly agree representing 31 percent, 9 agreed representing 15 percent, 26 disagreed representing 44 percent and 6 strongly disagreed representing 10 percent. On the forth statement that the training does not provide for adequate practical for hands on experience, 20 respondents strongly agreed representing 34 percent, 22 respondents agreed representing 27 percent, 4 had a neutral view representing 7 percent, 9 disagreed representing 15 percent and 4 strongly disagreed representing 7 percent. The results show that there is a limited training capacity among the HSAs in Malawi. The results are presented in table 7 and figure 4 below. Table 7: Training capacity of HSAs as community health workers SN Statement Strongly Agree Agree Neutral Disagree Strongly Disagree 1 The training time for HSA Course is in adequate 48 (82%) 2 (3%) 0 (0%) 0 (0%) 9 (15%) 2 The training covers too much content 34 (58%) 9 (15%) 5 (8%) 7 (12%) 4 (7%) 3 The training does not offer adequate knowledge and skills 18 (31%) 9 (15%) 0 (0%) 26 (44%) 6 (10%) 4 The training does not provide for adequate practical for hands on experience 20 (34%) 22 (37%) 4 (7%) 9 (15%) 4 (7%) Figure 4: Training capacity of HSAs as community health workers On how to address the training challenges, the qualitative data shows a number of suggestions from the respondents as follows: Firstly, the HAS training should have enough time. Government should extend the period to at least one or two years training. Secondly, the training should have a reliable certification similar to other qualifications like nursing. Thirdly, government should build HSA Training Centers. The trainings are conducted at training conference facilities, the Ministry of Health should establish training centers of schools for HSA position across Malawi. Fourthly, HSAs should be provided with formal regular short courses or trainings on emerging diseases such as pandemics. 4.3.4 Objective 4: Capacity challenges faced by HSAs in executing their community health work The fourth objective was to examine the capacity challenges faced by HSAs in executing their community health work. The respondents were given statements on capacity challenges faced by HSAs in executing their work and asked to indicate the extent to which they agree or disagree with the given statement. The following were the statements: Community expect as to treat sick people just like doctors do; Community members want us to help their families just like family or personal doctors; We face so many diseases that requires attention of doctors; Communities look up to us on all their health problems; and Communities expect us to know everything about pandemics and vaccines as was the case with Covid-19. On the first statement that community expect HSA to treat sick people just like doctors do, 22 respondents strongly agreed representing 38 percent, 29 agreed representing 49 percent, 2 disagreed representing 3 percent and 6 strongly disagreed representing 10 percent. On the second statement that community members want HSA to help their families just like family or personal doctors, 14 strongly agreed representing 24 percent, 28 agreed representing 49 percent, 10 disagreed representing 17 percent and 6 strongly disagreed representing 10 percent. On the third statement that HSAs face so many diseases that requires attention of doctors, 29 strongly agreed representing 49 percent, 28 agreed representing 48 percent and 2 had a neutral view representing 3 percent. On the fourth statement that communities look up to HSAs on all their health problems, 41 respondents strongly agreed representing 70 percent, 16 agreed representing 27 percent and 2 had a neutral view representing 3 percent. On the last statement that communities expect HSAs to know everything about pandemics and vaccines as was the case with Covid-19, 41 respondents strongly agreed representing 70 percent, 15 respondents agreed representing 25 percent and 3 respondents disagreed representing 5 percent. The results show that HSAs face multiple work capacity challenge that are associated with increased expectations from the communities they serve. The results are shown in table 8 and figure 5 below. Table 8: Capacity challenges faced by HSAs in executing their community health work SN Statement Strongly Agree Agree Neutral Disagree Strongly Disagree 1 Community expect us to treat sick people just like doctors do 22 (38%) 29 (49%) 0 (0%) 2 (3%) 6 (10%) 2 Community members want us to help their families just like family or personal doctors 14 (24%) 29 (49%) 0 (0%) 10 (17%) 6 (10%) 3 We face so many diseases that requires attention of doctors 29 (49%) 28 (48%) 2 (3%) 0 (0%) 0 (0%) 4 Communities look up to us on all their health problems 41 (70%) 16 (27%) 2 (3%) 0 (0%) 0 (0%) 5 Communities expect us to know everything about pandemics and vaccines as was the case with Covid-19 41 (70%) 15 (25%) 0 (0%) 3 (5%) 0 (0%) Figure 5: Capacity challenges faced by HSAs in executing their community health work The respondents were asked to provide any additional capacity challenges faced by HSAs in executing their community health work apart from the ones provide in the table. The additional capacity challenges are that there firstly there are other HSAs that are trained in family planning whilst others are not which entails that those not trained have capacity challenges in handling family planning issues. Secondly, it was hinted that the HSAs do not have adequate skills to face the community needs. The community has higher expectations from the HSAs yet not all HSAs have adequate knowledge on some of the questions and health needs that are demanded by the communities. Lastly, the HSAs face capacity problems when there is a new diseases such as pandemics like how it happened with Covid-19 and its associated vaccines. Communities relied on HAS as their source for information on Covid-19 yet the HAS were also not well knowledgeable about the pandemic. 4.3.5 Objective 5: Measures used by HSAs to cope with the magnitude of work as community health workers The fifth and last objective of the study was to analyse the measures used by HSAs to cope with the magnitude of work as community health workers. Qualitative data was provided by asking the HSAs to indicate the measures they use to cope up with magnitude of work. The first coping up measure used is time management. The results show that HSAs try as much as possible to manage their time so as to execute multiple roles and responsibilities expected of them. Secondly, the work as a team. This helps by working jointly in our impact communities so that the workload is lessened with the support we get from fellow HSAs when one has a lot of people to serve that the other. Thirdly they make good use of village structures like village health committees to support us in activities like community mobilization during campaigns and tracing and making follow up on patients, children for vaccination, and other services like family planning. 4.4 Discussion of the Findings The findings of this study confirms view by Tulenko, et al., (2013) that community health workers are a key component of strategies to achieve universal health coverage, through extension of primary health services to underserved communities. HSAs receive a 12 weeks training (Nsona, et al., 2012). The findings have shown that the training is not enough considering the training content that focuses on multiple health areas such primary health care, family health and environmental health. The findings further show that once employed, HSAs are supposed to reside in their catchment area, working mainly in health promotion and prevention for a population of about 1,000 as observed by Gilroy, et al., (2012). The literature also indicated that: From 2008, HSAs’ curative tasks have been expanded. HSAs working in hard-to-reach areas conduct integrated community case management of childhood illnesses (iCCM) (Nsona, et al., 2012). This has been confirmed by the findings of the study has shown that the HSAs roles have further expanded with coming of Covid-19 pandemic, increase in Cholera cases and increased need for children vaccinations. HSAs are supported by village health committees (VHCs), consisting of ten unpaid village representatives elected by the community, and other volunteers, such as members of HIV support groups and traditional birth attendants (Kok & Muula, 2013). Working with community health structures such as village health committees has been revealed in this study as one of the ways of coping with HSAs workload challenges. The findings further agrees with Martiniuk, et al., (2014) that unrealistic expectations from the community regarding HSAs’ roles could hamper HSAs’ work. Competence motivation theory is a conceptual framework designed to explain individuals’ motivation to participate, persist, and work hard in any particular achievement context. The theory applied to this study has helped in understanding the high magnitude of HSAs work in Malawi and how the HSAs persist such work pressure to achieve results in a work environment full of challenges. The HSAs are motivated by the need to serve the communities. The findings show that HSAs in Malawi face workload challenges amidst increased demand for community health services in the country. The findings show that motivation of HSAs is affected by work pressure which is coupled by limited training that the HSAs get. Harter’s competence motivation theory (1978) is used to explain motivation to participate and withdraw. This theory represents an interactionist view of behavior, incorporating both individual and situational factors that impact one’s motivation. The findings show that limited training lead to capacity challenges that reduces the motivation levels of HSAs. According to Harter (1978), people are intrinsically motivated to master a domain that is challenging. If they are successful and they are supported, given approval, and positively reinforced by significant others, their perceptions of competence and control will increase. The findings show that HSAs have been resilient in their work despite challenges with most of them having worked as HSAs for an average of 20 years. 5 Conclusion The study was aimed investigating the role of Health Surveillance Assistants in promoting preventive health in Mulanje District. The study was guided by five objectives namely: to identify the roles of Health Surveillance Assistants in community health work; To explore the workload for health Surveillance Assistants; to explore the training capacity of health Surveillance assistants as community health workers; to examine the capacity challenges faced by HSAs in executing their community health work; and to analyse the measures used by HSAs to cope with the magnitude of work as community health workers. On the first specific objective of the study of identifying the roles of Health Surveillance Assistants in community health work it can be concluded that all the HSAs perform duties in community health, family health, environmental health and prevention and control of common community diseases. On whether the HSAs perform duties on management and administration it can be concluded that managerial and administrative duties are performed by senior HSAs that are considered as supervisors. On the second Objective of exploring the workload for health surveillance assistants, it can be concluded that HSAs faces a huge workload mainly because their duties are too broad, they serve too many people, NGOs use us for community work and that there are few community health workers (HSAs). The workload challenges can be addressed by employing more HSAs to reduce HAS to people ratio, have more training for the effective work of HSAs, have new system (technology) on reporting activities so as reduce time spent on writing reports, ease mobility challenges by providing HSAs with motorcycles, and providing HSAs with laptops for compiling information and executing their duties. On the third objective of exploring the training capacity of health surveillance assistants as community health workers, it can be concluded that the training time for HSA Course is in adequate; the training covers too much content; the training does not offer adequate knowledge and skills; and the training does not provide for adequate practical for hands on experience. On how to address the training challenges, the HAS training should have enough time. Government should extend the period to at least one or two years training, the training should have a reliable certification similar to other qualifications, government should build HSA Training Centers, and that HSAs should be provided with formal regular short courses or trainings on emerging diseases such as pandemics. On the fourth objective of examining the capacity challenges faced by HSAs in executing their community health work, it can be concluded that the capacity challenges are mainly there because the communities expect HSAs to treat sick people just like doctors do; community members want us to help their families just like family or personal doctors; communities look up to HSAs on all their health problems; and that the communities expect HSAs to know everything about pandemics and vaccines as was the case with Covid-19. It can further be concluded that capacity challenges are there because there are other HSAs that are trained in family planning whilst others are not and that the HSAs do not have adequate skills to face the community needs. On the fifth and last objective of analysing the measures used by HSAs to cope with the magnitude of work as community health workers, it can be concluded that the coping measures used by the HISAs are time management, working as a team and making good use of village structures like village health committees. Recommendations Based on the outcome of the research, the following are the key recommendations: a) Government must prioritise the HAS as a key community health profession in Malawi by looking into their workload, welfare and employing more HSAs so as to reduce workload challenges. b) There is a need to increase the training period for HSAs so the training is well certified and that the HAS position is well recognised as a profession. c) Government must establish a formal training school for HAS just as they do with other health professions such as nursing. d) Government must have a deliberate capacity building programme for HASs that should be able to provide HSAs with adequate capacity in new diseases such as pandemics. e) HSAs work should be ease by providing them with reliable transport means such as motorcycles so as to ease mobility challenges. f) HAS reporting systems must be improved by adopting technology oriented reporting system. REFERENCES Kadzandira, J. M. and Chilowa, W. (2001). The role of health surveillance assistants (HSAs) in the delivery of health services and immunisation in Malawi. Lilongwe: University of Malawi, Centre for Social Research. Lewin S, et al. (2010). Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. Lewin, S., M. Zwarenstein, I. B. Scheel, S. Munabi-Babigumira, C. Glenton, K. Daniels, X. Bosch-Capblanch, B. E. van Wyk, J. Odgaard-Jensen, M. Johansen and G. N. Aja. (2010). “Lay Health Workers in Primary and Community Health Care for Maternal and Child Health and the Management of Infectious Diseases.” Cochrane Database of Systematic Reviews. Martiniuk, A (2014). Getting Treatment and Care to the Last Mile: Analyzing the Health Surveillance Assistant Cadre in Malawi. Retrieved on 4 June 2023 from https://www.files.ethz.ch/isn/176094/AI_DP_10.pdf Ministry of Health (2009). Health Surveillance Assistant Facilitator’s Guide. 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| Keywords: | Health Surveillance Assistants Health Surveillance Assistants (HSA) are Primary Health Care workers serving as a link between a Health Facility and the community (HSA Facilitator Guide, 2009). Community Health Workers Community Health Workers (CHWs) are a key component of strategies to achieve universal health coverage, through extension of primary health services to underserved communities at low costs in contexts of chronic financial and human resource shortages (Tulenko, et al., 2013). Preventive Health According Centre for Disease Control (CDC), preventive health refers to routine care you receive in order to maintain your health. It emphasizes on the importance of diagnosis of medical conditions before they become a problem. |
| Cite Article: | "The role of Health Surveillance Assistants in Promoting Preventive Health in Malawi: Case of Mulanje District", International Journal of Novel Research and Development (www.ijnrd.org), ISSN:2456-4184, Vol.9, Issue 1, page no.c708-c740, January-2024, Available :http://www.ijnrd.org/papers/IJNRD2401292.pdf |
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Published Paper ID:IJNRD2401292 Registration ID: 213176 Published In: Volume 9 Issue 1, January-2024 DOI (Digital Object Identifier): Page No: c708-c740 Country: Blantyre, Blantyre, Malawi Research Area: Social Science and Humanities Publisher : IJ Publication Published Paper URL : https://www.ijnrd.org/viewpaperforall?paper=IJNRD2401292 Published Paper PDF: https://www.ijnrd.org/papers/IJNRD2401292 |
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