Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi

Abstract

Since the Alma Ata Declaration in 1978, community health volunteers (CHVs) have been at the forefront, providing health services, especially to underserved communities, in low-income countries. However, consolidation of CHVs position within formal health systems has proved to be complex and continues to challenge countries, as they devise strategies to strengthen primary healthcare. Malawi’s community health strategy, launched in 2017, is a novel attempt to harmonise the multiple health service structures at the community level and strengthen service delivery through a team-based approach. The core community health team (CHT) consists of health surveillance assistants (HSAs), clinicians, environmental health officers and CHVs. This paper reviews Malawi’s strategy, with particular focus on the interface between HSAs, volunteers in community-based programmes and the community health team. Our analysis identified key challenges that may impede the strategy’s implementation: (1) inadequate training, imbalance of skill sets within CHTs and unclear job descriptions for CHVs; (2) proposed community-level interventions require expansion of pre-existing roles for most CHT members; and (3) district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is needed on the appropriate forms of CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload, strengthening coordination and communication across all community actors, and financing mechanisms. Policy support through the development of an addendum to the strategy, outlining opportunities for task-shifting between CHT members, CHVs’ expected duties and interactions with paid CHT personnel is recommended.

Feasibility and acceptability of a novel community-based mental health intervention delivered by community volunteers in Maharashtra, India: the Atmiyata programme

“…The leadership roles they played in the community, their manner of approach and their intrinsic motivation to support their communities are important factors. Scaling-up community volunteer-led models must be carefully thought through; the debate is ongoing as to whether it is ethical to not incentivize volunteers, particularly in disadvantaged or impoverished communities [34]. Some programs have provided incentives in the form of bicycles, mobile phones, and clothing, while others offer small stipends or sitting allowances to conduct activities [35].…”

Integrated Management of Childhood Illnesses (IMCI): a mixed-methods study on implementation, knowledge and resource availability in Malawi

“… 18 Health centres, dispensaries and rural clinics deliver primary care and are linked to community care via Health Surveillance Assistants (HSAs). 19 Secondary care is delivered at district hospitals and regional referral hospitals provide tertiary care. A summary of healthcare workers and their roles are presented in online supplemental appendix 1 .…”

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district

“…This paper is based on a sub-analysis of qualitative data from a larger mixed methods study, which examined local models for chronic care and self-management support in southern Malawi [36]. The primary dataset was collected within two rounds (April to July 2016, and March to May 2017), in Malawi, involving multiple methods and respondents [37].…”

“…three primary level facilities and the only two secondary level facilities providing referral services). These facilities were part of the catchment area of our larger study [36]. Interviewee selection aimed for representation and diversity by gender, professional cadre (clinical, non-clinical, and health managers with varying responsibilities in chronic care), and health facility category (public and private; PHC and referral facilities).…”