Task-shifting and prioritization: a situational analysis examining the role and experiences of community health workers in Malawi

Globally, 57 countries face critical heath workforce shortages and more than four million health workers are needed to fill this gap [1]. Such shortages of human resources for health combined with the double burden of infectious and chronic diseases contribute to increased mortality and morbidity, impede the achievement of the health-related Millennium Development Goals, and hinder economic growth in low- and middle-income countries. Given this human resource gap, particularly in rural areas, there is renewed interest globally in the potential for community health workers (CHWs) to take on an expanded role in strengthening health systems [1].

Many countries developed national programmes for CHWs following the Alma-Ata Declaration on primary health care in 1978. CHWs are the first point of care and typically work at the household level [2]. They are widely employed across Africa and Asia and to a lesser extent South America and occasionally in the USA and UK. Typical roles include: nutrition, maternal and child health promotion, childhood immunization, infectious disease control and implementation of noncommunicable disease interventions [1].

The World Health Organization (WHO) supports the use of CHWs in countries such as Malawi with a shortage of health workers (two doctors per 100,000 people) and a high disease burden [3]. The WHO stresses the importance of having a national framework to guide task-shifting, clearly defined roles, consultation with all cadres, strong training, adequate supervision and regular assessment [4].

Several existing systematic [5, 6] and nonsystematic reviews [7, 8] provide evidence that CHW interventions can be effective in malaria prevention activities including the distribution of insecticide-treated nets and that CHWs can increase immunization coverage, improve breastfeeding rates, and show promising benefits in improving tuberculosis (TB) treatment outcomes and neonatal survival when compared to usual care. There is limited information regarding CHW training, supervision, prioritization of tasks, and challenges faced across multiple service delivery responsibilities. Amidst the research evidence, few studies have given voice to CHWs in low- and middle-income countries [9, 10].

CHWs in Malawi are called Health Surveillance Assistants (HSAs). Initially they were called Cholera Assistants when first recruited in 1973 by the public health unit to fill a human resources gap and manage a large cholera outbreak [11]. Following the Alma-Ata declaration the position was renamed. In 1998, the Ministry of Health (MOH) recognized a growing need for the provision of health services at the community level and renamed Primary Health Care workers to the current title of HSA while making HSAs position within the health sector permanent [11, 12]. HSAs are now employed within the Environmental Health Department [11]. According to the HSA job description, Assistant Environmental Health Officers are the formal supervisors of HSAs, however the more experienced Senior HSA position, also called HSA supervisor, provides the majority of direct supervision to HSAs [13].

According to the job description, the qualification of HSA is awarded to those who have completed the Malawi School Certificate of Education or Junior Certificate of Education and the MOH-approved HSAs’ pre-service training programme [13]. As the role of the HSA has evolved, so too has the HSA pre-service training programme. This was initially of six weeks duration but has been gradually increased to eight, then ten and now twelve weeks [11]. According to MOH documents, 5% of HSAs nationally are yet to receive pre-service training [11].

Today, HSAs comprise 30% of the health workforce in Malawi and they are often the only health workers serving rural communities where they are expected to reside [14]. The targeted ratio of HSAs to population is 1:1,000 [11]. The cadre is largely responsible for community-level delivery of the MOH Essential Health Package, being the minimum services provided to all Malawians free of charge [14]. Most recently, as part of the Essential Health Package, HSAs have been asked by the MOH to deliver community case management (CCM), an extension of the integrated management of childhood illness (IMCI) approach at the community level [15]. The MOH considers the three primary roles of the HSA to provide promotive, preventive and curative care; promote community participation in health care activities and to provide disease surveillance services at the community level [11].

It has been well documented that new activities such as microscopy and HIV testing and counselling are regularly being added both formally and informally to the HSA role and existing activities are being scaled-up using HSAs [13, 16]. Generally, the effectiveness of scale-up programmes involving CHWs has been difficult to determine given the variation in the scale-up approach and the difficulties measuring outcomes [5‐8, 17]. However, locally the Médecins Sans Frontières experience in Thyolo district Malawi provides some evidence of feasibility and good outcomes for a programme of decentralized HIV care to clinics and community settings using task-shifting in which HSAs provided the HIV testing and counselling, and, treatment initiation was transferred to non-physician clinicians [18]. Between 2003 and 2009, the programme achieved universal access targets and achieved significant gains in human resources efficiency [18]. As such, the MOH continues to train and certify HSAs in HIV testing and counselling with the help of nongovernmental organizations (NGOs), such as Médecins Sans Frontières, who recognize the need for task- shifting this role to HSAs given the severe shortage of higher-level health workers [18]. The MOH has also reported that it aims to expand certain programmes, such as TB treatment, with HSAs as the primary providers [16].

A situational analysis of the HSA cadre in Zomba district Malawi was undertaken in order to comprehensively understand the HSA cadre’s role, training system and supervision. Reported here are the findings from the cross-sectional assessment of the HSAs’ performed versus documented roles and the examination of prioritization of tasks by HSAs, their supervisors and policy-makers.

The HSA role in Malawi has been evolving as the health needs and the capacity of the health system to provide services has changed. Being the only community-based health care cadre, a link between villages and health centres, and a sizeable workforce has meant HSAs have the potential to provide more equitable access to health services. HSAs have enabled the MOH to push forward specific health agendas, particularly the Essential Health Package, which placed them at the forefront of large scale prevention campaigns such as childhood immunization through the Enhanced Programme of Immunizations and malaria campaigns. Most HSAs, HSA supervisors and policy-makers felt preventive tasks were and should remain the priority for HSAs. They appreciated the potential benefits in reducing the burden of disease and mortality and recognized the economic advantages for a strained health system.

However, the role of the HSA has continued to expand beyond prevention to include tasks that are curative in order to respond to disease priorities. The MOH has now listed ‘curative’ in the definition of HSAs’ primary role [11], however some HSAs remained adamant that it was not within the scope of their practice to offer treatments. There were varying opinions about whether HSAs should perform curative tasks amongst both HSAs and policy-makers.

Due to shortages in human resources, there has been an increasing demand on HSAs to perform health centre-based duties such as microscopy, drug management, under fives clinics and HIV testing and counselling. While having an interface between community and health centres was considered essential to effectively fulfilling their function, this study highlighted HSA and policy-maker concerns that increased time spent in health centres results in neglect of community-based prevention tasks. The Malawi-appointed task force review of HSA job descriptions in 2011 concluded that HSAs spent on average 65% of the time in the communities and 35% in the health centres [13]. The MOH argued that this was not the intended role of the HSA and ‘something needs to be done in order not to lose the direction of having the HSAs as community-based health workers’ a sentiment echoed by both HSAs and policy-makers in this study [11], p.12.

HSAs were being used across Zomba district by NGO and MOH programmes to provide a range of services beyond the scope of the current job description. The task force review of the HSAs’ job description suggested including HIV and TB defaulter tracing and treatment monitoring activities, HIV testing and counselling, pre-antiretroviral therapy activities, dry blood spot sampling tests for malaria and family planning interventions in a revised job description given HSAs were perceived to be performing the tasks routinely and safely across Malawi [13]. Most policy-makers noted that IMCI CCM village clinic and many of the additional tasks HSAs performed, would ideally be provided by more highly qualified personnel but HSAs were considered the most appropriate cadre currently and could not be removed from the essential tasks until there was a significant increase in numbers amongst other cadres at health facilities [13].

Including additional tasks formally in a revised job description and ensuring all HSAs are familiar with their job description would likely serve to reduce confusion and resultant frustration for HSAs which was evident in this study. A revised job description would clarify what is and is not the role of the HSA; a condition necessary for improved worker satisfaction and morale [22]. Interestingly, this study gives a sense of the willingness of HSAs to expand and even change the scope of their practice in response to heath priorities given appropriate training and resources. Previous global work has shown that meeting community expectations, engaging with communities and providing communities with services they consider valuable remains essential to the success of any ongoing CHW programme [8].

Most policy-makers and many HSAs felt they were being given more tasks than they could handle which distracted them from their intended roles in the community. Several other studies have also found that the ever-increasing workload was a serious issue for HSAs [11‐13, 23]. Attention needs to be paid to this issue, as effective task-shifting is unlikely if HSAs are overwhelmed by the number of tasks [22]. Continued focus is needed in ensuring HSAs have access to vital resources such as transport, mobile phones and accommodation that would increase efficiency and capacity to perform the larger role [22].

This study raised questions about whether to continue training HSAs broadly and then have some focus on certain task such as HIV testing and counselling or whether to recruit and train workers specifically for HIV programmes for example, so HSAs could remain broad-based community, preventive health workers. It is recognized in the literature that a lengthy and unresolved debate has continued in regards to specialization of CHWs in terms of how many tasks one can carry out given the scope of potential activities along with questions about what the primary role actually is [1, 8]. It has been suggested that specialized CHW roles may occur due to the difficulty governments have in finding the optimum mix of roles and tasks and the ideal balance between depth and breadth of tasks [8]. This current dilemma for policy-makers on the specialization of HSAs warrants further research and debate - especially in light of the new moves to also have HSAs take on roles in chronic disease surveillance and management [24, 25]. It is worth noting that none of the written, observed or collected data in this study referred to chronic diseases despite these increasingly accounting for much of the disease burden in low- and middle-income countries [26].

Although NGO tasks were seen as complementing government efforts, the lack of integration, vertical programming and multiple supervisors associated with NGO programmes meant competing demands on HSAs to prioritize activities which contributed to overloading and compounded role confusion. In this study, there was evidence that pressures existed at the community level to prioritize disease-specific programmes over the core duties outlined in their job descriptions. There is concern in the literature about the negative consequences to the broader health system of global health initiatives which have a disease- specific focus, in particular those related to the scale-up of HIV activities [27]. It is also recognized that specialization is often an unintended consequence of such disease-specific programming [8]. Some HSAs struggled to meet the demands of their role because of distraction from, or even diversion entirely to, programme-specific activities.

Policy-makers expressed concern about the lack of policy and MOH ‘control’ that had resulted in the fragmentation of programmes, training and supervision. There is evidence in the literature that effective task-shifting requires leadership from governments in establishing policies, engaging stakeholders, supporting training, and providing adequate resources [28]. There was a feeling amongst policy-makers which is echoed in the literature, that better organized programmes and improved supervision would allow HSAs to manage the work load more effectively and potentially see the benefits of the HSA cadres’ role applied to a greater range of health priorities [8, 22]. Improved collaboration within the MOH itself and improved collaboration between the MOH, other government departments and NGOs in planning and implementing programmes may improve integration and the capacity of HSAs to meet the demands of an ever expanding role. The IMCI CCM village clinic could serve as a model for other programmes as it has demonstrated effective collaboration between sectors and government departments, is strongly led by the MOH, and its policy directs the work of partners and provides a framework for the coordination and partnership of many organizations [15].

This study’s findings have been actively disseminated to various HSA stakeholders within Malawi, including the Zomba District Health Management Team and national-level HSA policy-makers from the Essential Health Package Technical Working Group - a key HSA policy-making forum.