The reported and observed experiences of HSAs, their supervisors and policy-makers was analysed and compared with the current job description and the HSA pre-service training curriculum to compare the HSAs’ performed versus documented role.
Task-shifting
Respondents acknowledged that the job description of HSAs had evolved and changed many times with the influx of new programmes and according to health priorities. Additional tasks were assigned informally to HSAs by both the MOH and local NGOs who coordinated the specific programmes. As such, the job description did not include the full range of tasks HSAs currently performed. One HSA stated:
‘Not all the works we do were written on the job description because there are other organizations which use us. So we cannot say that we only follow what was written to us by the government’.
In contrast, policy-makers indicated that the central MOH was responsible for task allocation across the health system. As one policy-maker noted:
‘Any activity before it is being done by the HSAs, the people on top there at the central level they sit down and decide who should this activity be given to; is it for clinical staff, is it for nursing, is it for environmental? So, once the people agree up there, then they just tell us and we have to tell them to do that job’.
Many HSAs saw the addition of tasks as inherent in the role as the job description stipulated ‘any other duty assigned’ such that they must comply when asked by seniors to perform a task outside their scope. One HSA said:
‘ Sometimes some (tasks) we add which are not in the letter (job description) but when we are told to do them, we have to do’.
The additional tasks varied across Zomba district and between HSAs. The tasks not explicitly listed in the job description or taught comprehensively within the pre-service training curriculum being undertaken by HSAs in Zomba district were:
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Nutrition supplementation programmes for malnourished children at facilities;
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TB testing, drug dispensing, patient review;
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Dispensing and administering injectable contraceptives within family planning activities;
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Antiretroviral therapy for HIV - dispensing and monitoring, defaulter tracing and pre-antiretroviral therapy activities such as encouraging blood tests and engagement with health centres;
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Performing dry blood spot testing for infants within prevention of mother to child transmission of HIV (PMTCT) programmes
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Cholera management at health centres;
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Drug store management; and
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Outpatient register at the facility.
HSAs and policy-makers acknowledged that many of the additional tasks were activities traditionally and ideally performed by more qualified health workers. TB treatment activities, nutrition programmes, family planning and antiretroviral therapy activities were frequently identified and accepted by many HSAs as routine tasks within their role. One policy-maker stated:
‘In TB activities, they are the HSAs who are doing the work, they are the ones going out tracing the patients, they are the ones distributing drugs in the health facilities’.
The integrated management of childhood illnesses (IMCI) community case management (CCM) programme known as ‘village clinic’ was an example of a task recently added to the current HSA job description that was yet to be added to the pre-service training curriculum provided by the MOH. The programme required HSAs to assess children aged two months to five years in communities for common illnesses and provide basic treatments and referral:
‘Things pertaining to village clinics (IMCI CCM)…we know that they are supposed to be done by (higher-level) medical assistants but we do them. We know that it is their work, but bearing in mind that the government desires that people access assistance in their villages, we offer them. You may realize that in our villages we offer first treatment especially to the infants and this happens to be our additional task’.
Some HSAs expressed frustration that they were expected to take on tasks for which they were not qualified:
‘The work that I do but though am doing it I don’t feel happy with it is village clinic (IMCI CCM) because I am not a doctor and I was not trained for that (performing IMCI CCM) I am just a health worker (HSA)’.
HSAs did not only take on roles above their perceived skill set but also below. Some HSAs expressed frustration about performing duties such as cleaning at health centres or data collection outside of their normal role:
‘We went there and collect it without telling us what they want to do with the collected data. They just tell you a certain NGO wants it. Things like those are the ones I don't like’.
Preventive versus curative
Many HSAs spoke of a shift in their role from an environmental health and disease surveillance role to a role which included providing treatments. One policy-maker stated:
‘In the past they were more focused on preventive health, usually doing environmental health activities, as well as disease prevention and control, but now since they are also being involved in curative as well as family planning method and alike, it’s like now they are involved almost in all activities’.
For some HSAs the expansion of their role to include treatment tasks caused confusion:
‘ Our main tasks is preventive so we are wondering that we are now doing the curative like the village clinics (IMCI CCM) - we have medicines’.
Opinion was divided amongst HSAs about the delivery of the IMCI CCM village clinics. Many saw it as a priority from a health promotion and prevention perspective as it reduced barriers to access, fitted well at the community level and communities valued it:
‘Another duty that satisfies me in the village is of village clinic (IMCI CCM) because parents get used to you when you are helping the kids. You being a fellow villager, they know you, get close to you; they trust you and they depend on you. Because they know that even if during the night a child falls sick, they rush to you knock on your door, and when you give them treatment’.
Others considered it clinical, not preventive, and therefore the responsibility of other cadres of health workers. Despite the majority of HSAs who participated in the study having received training for IMCI CCM village clinics via workshops, some felt insufficiently trained to perform the tasks and worried about the consequences to themselves and others by potentially misdiagnosing, mistreating or causing harm inadvertently:
‘We met different cases (diseases)…sometimes we fail to handle these just because of lack of knowledge or skills, and we also failed to help people even simple cases due to lack of knowledge’.
‘Giving medication in the village is a difficult work, it needs proper training in order to know what you are doing with your patients because medication sometimes are poison to patients, if you cannot give them relevant medication to the disease it can cause another disease’.
HSAs were being called upon increasingly to fill clinic-based human resources gaps and support health centre activities:
‘Due to task-shifting - where maybe some (higher-level) health workers are not available, that’s when you find HSAs providing some services at the facilities’.
Some saw an advantage in this as it enhanced links with centre-based services. Some HSAs felt confident and enjoyed doing centre-based tasks but others thought such tasks should not be allocated to HSAs:
‘They should not give us more programmes as HSAs just because they have a lot of pressures, for instance clinic work it’s not our part’.
The amount of time spent in clinics varied. HSAs in one centre spent one week per month away from their village catchment while in another, HSAs reported that 50% of their time was spent in facilities. A concern expressed by HSAs, their supervisors and policy-makers was that if too much time was spent filling gaps at the health centres, the preventive efforts in the catchment areas would suffer:
‘We get disturbed with clinic work because we have to be here for one week and another one week at (another centre), so two weeks at one month…sometimes we fail to work for the community’.
Training inadequate for tasks shifted
In addition to pre-service training, which HSAs had received to varying degrees, additional formalized training for new or specific tasks was being provided by the MOH and/or relevant NGO responsible for programme delivery. In view of their expanding role, most HSAs, supervisors and policy-makers felt that the training HSAs received was inadequate:
‘Relating to the work they are actually trained for…it seems it is adequate…But looking at the task-shifting, for the task-shifting issues they need to learn even more’. (Policy-maker)
Some of the additional tasks that had shifted to HSAs were performed without formalized training:
‘ART (antiretroviral therapy) we did it without proper training’.
‘I do work without any training…we deal with distribution of food to children who are malnutrition’.
HSAs reported that often not all HSAs received additional formalized training in new or specific tasks. Commonly, one or two HSAs at each centre were trained in new tasks such as administering family planning injections, and they then briefed their peers on how to perform them:
‘Like giving out TB medication, we just watch our friends who went for training even though we did not go for special training that this is how TB medication is given’.
‘Every Monday we must have a meeting…the one (HSA) who went to be trained on what has come have to brief the others (HSAs). That means when he has briefed us, we go and do what he has told us’.
There were varying opinions amongst HSAs on the adequacy of this seemingly informal peer-led training. Some HSAs commented that they were performing tasks confidently after being trained by a peer on-the-job. A few HSAs and a policy-maker expressed a fear that informal on-the-job training could result in HSAs passing on incorrect information or techniques. One HSA suggested training more than one HSA at each site to enhance the quality of on-the-job peer-led training:
‘They send information through someone we did not get it clear, so they found weakness that we don’t do our work. May be the reason can be a person did not get information clear…they should train two or three, five people it can be good because it can help us to get the information clearly’.
Some HSAs expressed frustration with what they saw as a misallocation of training to other cadres, particularly nurses who received longer training and larger allowances while HSAs implemented the activities at the grass roots level:
‘So we wanted that training because for that training, they mostly just focus on nurses but when it is for work, it comes to us the village workers (HSAs)’.
Many HSAs said they were not competent or happy to perform tasks for which they had not been trained:
‘ Every job that we have been taught, it is the one that we happily carry out. As compared to the job may be they have given us that you should do this job, we do not know it and we have never learnt, it is the one that we are not happy with.’
Task-shifting without appropriate supervision structures
HSAs, HSA supervisors and policy-makers all identified weaknesses in the supervision of HSAs and this was seen as a significant issue particularly when new tasks were being added to HSAs’ duties. Policy-makers in particular highlighted a lack of integrated supervision, even across MOH departments as a constraint to HSA effectiveness:
‘I don’t know what other supervisors are doing…we don’t go as an integrated programme. …it’s usually maybe the nursing (department)…supervise them on the clinical component…maybe the preventive (department) will go also’. (Policy-maker)
‘So you will find that the HSA has got multiple supervisors…There is the Assistant Environmental Health Officer or Environmental Health Officer who is supposed to be the supervisor....But depending on what (tasks) they have given him…the HSA is not supervised proper because each programme manager, each programme coordinator, wants to supervise an HSA on the work that his programme has given the HSA’. (Policy-maker)
One policy-maker said that the Assistant Environmental Health Officers and Environmental Health Officers who supervised the HSA supervisors were not receiving training for tasks shifted to HSAs, thus restricting their capacity to effectively supervise HSAs and HSA supervisors:
‘We are targeting the HSAs…these other cadres of their supervisor the Environmental Health Officer, the Assistant Environmental Health Officer; they are being left out…How can you supervise something you don’t know?’
Lack of remuneration or resources for shifted tasks
Participants noted that while the role had expanded, the remuneration had not increased accordingly and HSAs who performed specialized tasks were not receiving allowances:
‘Another thing that I see as a problem on our work is the abundance of the work which we receive to do, comparing to what they employed us for. So it seems we do a lot of work but we receive peanuts’.
‘That health worker (HSA) is doing probably the same that the nurse could do but the nurse is getting more so we go into that type of conflict’. (Policy- maker)
Most HSAs in this study felt that the remuneration they received did not reflect the value of their role and considered it a sign that the MOH did not value their contribution. Many HSAs said their role was hampered by a lack of medical supplies, office supplies, protective equipment, bicycles and mobile phone credit.
Role confusion
Contributing to confusion around the scope of the HSA role was that many - 30 of 70 HSAs asked - did not have a copy of their current job description. They referred to their training notes and curriculum as outlining their role or had seen previous versions only. Neither accurately reflected the current MOH job description for HSAs:
‘We don’t have a letter of our job description they only brief us what we have to do’.
Prioritization of HSA tasks
Priority on prevention and community
Consistent with the job description, HSAs frequently described their job as ‘community- based’ and ‘grass roots’ within a designated catchment area. They spoke about their role in building relationships with village leaders and the communities they serviced, as well as encouraging community participation in health care. Many HSAs and policy-makers referred to HSAs as a bridge or link between communities and the health system.
HSAs, HSA supervisors and policy-makers agreed that the HSAs’ preventive role in the community was most important and should remain a future priority. They recognized the potential to reduce disease burden, mortality, morbidity and demands on overburdened health facilities. An economic benefit to prioritizing prevention was recognized also:
‘My plea is that we should continue giving them (HSAs) the right support and doing more on preventive health services. You know prevention is cheaper and is simple…’(Policy-maker)
Many HSAs expressed pride in the importance of their prevention role and the benefit of their work to the population:
‘When we hear that this year in our country the report reveals that there is zero outbreak of such diseases we become very happy…when there is zero report it means that the one who has tried to do a very important job is we the HSAs in the community’.
Priority on access and equity
Because of their location in the communities, their numbers and skill mix, there was a perception that HSAs had the potential to effectively and efficiently provide more equitable access to services:
‘Those people (HSAs) are very close to the community so for any public health intervention they are close to the people and they would carry that very well and dissemination of that promotion would be even faster and more effective’. (Policy-maker)
HSAs valued their role in improving access to health care and they prioritized community health needs:
‘I organized a meeting with the villagers last week, they thanked me that this time around more children are not walking long distances because at first they were going to the (health centre) but now they are accessing the services in their village and this has to continue’.
‘People were not attending (health centre) because they were not having money for the treatment so today we are happy because we are helping them freely not paying so cases like people delaying to go to hospital may be children dying at a household are few…because we are giving them medications’.
Many HSAs wanted training to provide additional essential services such as HIV testing and counselling in their communities where they identified a need and demand:
‘If possible government should teach all HSAs in HTC (HIV testing and counselling) and family planning in order to help people…what happens when we are working in the community giving treatment, people ask us if we can provide to them these services, so like to my village, the health centre is very far and other people just stay without knowing their (HIV) status’.
Task-shifting and prioritization challenges
Overloading
Many HSAs felt they had been assigned too many tasks by the MOH and local NGOs such that they were overloaded:
‘Since we are in the village, right, they depend on us. They know that it is us who live with the children from the time they are very young. So, whatever programme comes, comes to whom? To us’.
Some HSAs said they were unable to fulfil their job description and neglected to perform some activities because of the additional tasks.
‘These other activities consume much of our time and instead our normal duties do not bear results in good time as we are preoccupied with other duties’.
Some HSAs felt they had too many jobs to be able to do them all well:
‘We have a lot of jobs, so for you to become an expert at a particular job it becomes difficult because if you are to do a job you should put your heart into it, another one comes that you should do such, so we have a lot of jobs so that it becomes difficult to pick out one job that we are good that, the jobs are just too many’.
In contrast, some policy-makers believed HSAs were not overloaded. They believed poorly organized and non-integrated programmes and ineffective supervision made it difficult for HSAs to incorporate additional tasks and manage their workload:
‘They (HSAs) just need to be mentored to make proper programmes for the community interventions…they just have to organize themselves and make a good programme for that…they will be complaining; no, we are loaded with a lot of roles. But if you could critically review what they have done in a month…you just see that it just need organization’. (Policy-maker)
Some policy-makers believed that many additional tasks were easily incorporated and offered when conducting routine community activities:
‘You are in this community you are teaching the people about family planning, why don’t you spare some minutes to also teach these people about sanitations?’ (Policy-maker)
Specialization
Specialization occurred when some HSAs received additional training which allowed them to perform specific ‘specialized’ activities such as HIV testing and counselling, drug store management, and TB sputum microscopy testing:
‘Sometimes it overloads. For example in my case, I did training in drug store management; it needs you to be there full time. If you have been assigned three days there, you have to make sure that everything there is working. It at the same time happens that in the field the work is intense as well, things are not working’.
‘So, when time comes to conduct our normal duties, you find that the same time you are required to attend clients at the office as a counsellor. It happens that my friends do worry because I am unable to perform my duties as HSA, it affects us a lot’.
Some policy-makers believed specialization of HSAs was required to meet health priorities:
‘Why not specialize if we want some HSAs to be doing family planning, they should look into that’.
Other policy-makers feared that specializing HSAs risked losing the benefits of a broad-based community cadre focused on prevention and health surveillance:
‘My fear is if they become specialized, we risk to them…they were supposed to keep a watchful eye on what is happening in the community setting’.
Specialization caused differences within the cadre which may have implications for remuneration:
‘Are we giving this HSA new title? Or are we keeping him as an HSA? Now how different is this HSA to the rest of the HSAs?’ (Policy-maker)
Many HSAs believed that all HSAs should be trained in current specialized activities as opposed to specialization. In this way, HSAs saw that they could support colleagues in sharing duties at the facilities:
‘So, it could be better if more counsellors were trained so that any time the HSA is here (health centre), he or she would have knowledge to do the work’.
One policy-maker highlighted the disparity and possible tensions amongst HSAs that may occur with increased specialization and suggested an alternative to recruiting and specializing more HSAs was needed:
‘We need to look at the issue of task-shifting and we aren't asking are we shifting the tasks to only a few group of HSAs and then they form their own colony and consider themselves different from the other HSAs that are working in the general community setting’.
HSAs highlighted a potential negative consequence of specializing:
‘We do face some challenges that when they see a health worker HSA they think that he or she was trained in everything…it could be better if they train all of us on family planning services so that our community could access the services without difficulties’.
Competing priorities at the local level
HSAs spoke of multiple programmes and supervisors at the local level placing competing demands on them to prioritize their activities. Policy-makers noted the lack of integration of NGO programmes and the implications this had on task-shifting and prioritization locally:
‘You find that some of the NGO they don’t do integration, they just want their programme to be done at that particular time…managers are biased towards their programme because everyone wants his programme to work. Yeah, so with that thing, it is like the HSAs now start losing focus to other activities which also they are supposed to implement’. (Policy-maker)
Policy-makers said tasks were being prioritized almost exclusively over others depending on demands made or incentives offered from well-funded programmes, thus diverting HSAs from core community duties. In this way, specialization of the HSA may have been an unintended consequence of disease-specific programming:
‘That’s why the HSA sometimes, may focus on only one area probably because that area is well funded’. (Policy-maker)
Several policy-makers expressed concern that the MOH did not have ‘full control’ of tasks allocated to HSAs. One respondent said NGOs had been bypassing the district supervisor of HSAs and directly recruiting HSAs for their programmes. As such, a directive was issued in July 2012 advising local organizations that access to HSAs must be arranged via the District Health Management Team. One policy-maker raised concerns about the sustainability of local NGOs using HSAs to implement programme-specific activities:
‘One of the (programmes) was HIV/AIDS, it was well funded, well supported. Those they were coordinating the programmes were attracting HSAs often, they needed data, needed this and that…I think the project was very attractive to the health workers…until issues of sustainability came up and they started scaling down’.