Frontline Vaccinators and Immunisation Coverage in Malawi

Abstract

Access to health services for the poor, especially in the Global South, is a major challenge to achieving health targets like those under the millennium development goals. In Malawi, health surveillance assistants (HSAs) have been instrumental in bringing health services, including immunisation, to remote areas amidst an acute shortage of professional healthcare workers. On the basis of ethnographic fieldwork and historical sources, we describe and analyse the roles played by HSAs in delivering immunisation in Malawi. As frontline vaccinators, HSAs work under adverse conditions with low remuneration, rare upward career mobility and inadequate equipment. All the same, HSA immunisation services are generally considered satisfactory by supervisors as well as by caretakers/mothers among the local population. Without adequate resources for the supervision and continuous training of HSAs, however, the quality of immunisation and other services may be compromised. Unlike professional healthcare workers like nurses and doctors, HSAs undergo only limited training and can be easily replaced. Such a situation makes them vulnerable, a scenario which throws up a cruel paradox: in the HSAs' vulnerability lies the key to the health system. Amidst high unemployment and poverty levels however, the admittedly low salaries help to retain HSAs and enable them have a better life than most Malawians who live below the poverty line. The Malawi case demonstrates that, rather than relying on unpaid volunteers, community health work can be sustainable if the workers have a secure salary mainstreamed within the public health sector.

Keywords:

• health surveillance assistants
• immunisation
• child health
• millennium development goals
• community health workers

Notes

¹The relative success, measured in terms of high vaccination coverage, has motivated this research project, which sought to analyse how immunisation can be implemented successfully in a context of a weak health system and high poverty levels. Malawi Health Sciences Research Committee granted ethical approval. The project was financed by the Research Council of Norway, Project number 143176–120577.

²Our empirical data are based on 3 separate ethnographic fieldworks. Two fieldworks of five months each, in several rural locations in Thyolo District, were conducted in 2010 by Mette Ommundsen and Kristin Alfsen, master students of anthropology. This fieldwork focused on health workers and their interaction with the local communities. Lot Nyirenda conducted 6 months' fieldwork at the district level in Dowa and Thyolo, as well as several structured and semi-structured interviews with national-level actors in 2010 and 2011. Interviews were conducted in English and Chichewa by Lot Nyirenda, a native speaker, with the help of 2 assistants. Lot also has many years of work experience in the field as a researcher in Malawi. In addition, Rune Flikke made several shorter research visits to Malawi in the period 2008–2011, participating in NGO meetings, conducting semi-structured interviews with medical practitioners a the district level and participant observations at 2 rural clinics.

³Malawi Multiple Indicator Cluster Survey: http://www.nso.malawi.net/data_on_line/demography/mics/MICS%20Report.pdf. Accessed 3 October 2011.

⁴Addressing the Electricity Access Gap: Background Paper for the World Bank Energy Sector Strategy. June 2010. Available at: http://siteresources.worldbank.org/EXTESC/Resources/Addressing_the_Electricity_Access_Gap.pdf. Accessed: 7 March 2012

⁵Malawi's immunisation profile: http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofileresult.cfm?C=mwi. Accessed 3 March 2012.

⁶Government health centres without electricity in rural areas store their vaccines at the CHAM facilities. Some of the refrigerators at the CHAM health facilities are supplied by the Ministry of Health.

⁷Dr Banda eventually returned to Malawi in 1958 to lead the struggle for independence.

⁸Even in such institutions, many scholars, like Jack Mapanje, were detained without trial.

⁹This comes in addition to the usually cited reasons of competing priorities due to inadequate resources. See Pachai (1972) and the Malawi Growth and Development Strategy 2006–2011: http://www.malawi-invest.net/docs/Downloads/Malawi%20Growth%20&%20Development%20Strategy%20August%202006.pdf. Accessed 10 October 2011.

¹⁰MSCE entails successful completion of 4 years of secondary education.

¹¹JCE entails successful completion of 2 years of secondary education.

¹²Within the civil service, grade M is above N.

¹³In our study districts, almost all immunisation activities we observed were carried out by HSAs.

¹⁴See Alfsen (2011) for a training schedule.

¹⁵For a full HSA job description as of May 2010, see Alfsen (2011), pp. 109–110.

¹⁶As indicated, HSAs recruited with funding from Global Fund did not receive any salaries during the first months of 2010, due to ongoing discussions within the health sector on whether to retain them after the expiry of funding from the Global Fund. A decision was made to retain the HSAs, and salary payments then resumed.

¹⁷The salaries of primary school teachers are generally higher than those of HSAs; the most qualified teachers received K23 297 per month in 2004 (Kadzamira, 2006, p. 16) while the highest-paid HSAs received K13 000 in 2011 (Alfsen, 2011).

¹⁸See: Eliminating Measles in Southern Africa. Available at: http://www.cgdev.org/doc/millions/MS_case_17.pdf. Accessed: 8 March 2012.

¹⁹These contraceptives are known as depot-medroxyprogesterone acetate (DMPA) (Katz et al., 2010).

²⁰The HMIS office based at the MoH headquarters has officers (Assistant Statisticians) at all district hospitals in the country.

²¹HSAs collect both the disease-specific programme data as well as HMIS data. By collecting such data, HSAs are, therefore, not only at the centre of delivering the SWAp's essential health package, but are also key to monitoring the delivery of services.

²²At the time of the study, HMIS officials based at all district hospitals were sending quarterly reports to headquarters in Lilongwe. Some health programmes (e.g. EPI, Tuberculosis) required monthly reports for their planning.

²³This was a hot topic, which surfaced on several occasions and at various levels in the course of a measles outbreak during fieldwork in 2010. See, e.g. Ommundsen (2011) and Alfsen (2011).

²⁴According to the Malawi EPI Programme, immunisation coverage data sent from the districts (i.e. administrative data) compare favourably with the coverage data from the 2010 Malawi Demographic and Health Survey.

²⁵MEHA was preceded by the Public Health Inspectors Association of Malawi (PHIAM), formed in 1990. The name was changed ‘to correspond to the change in name of the concerned professionals, i.e. Public Health Inspectors are now called Environmental Health Officers (with degrees) and Assistant Environmental Health Officers (with diplomas)’ (Available at: http://malawieha.org/node/1. Accessed: 7 March 2012). Some Environmental Health Officers however, felt that the PHIAM had been inactive for some time, such that the MEHA was more or less a new initiative, albeit with a long-distant predecessor.

²⁶At risk also are the children being injected, and this raises issues of legal suits.