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Base de données d'évaluation

Evaluation report

2001 MLW: The Role of Health Surveillance Assistants (HSAs) in the Delivery of Health Services and Immunization in Malawi

Author: Kadzandira, J.; Chilowa, W. Centre for Social Research, University of Malawi

Executive summary


For nearly a decade, Malawi has enjoyed very high immunization coverage rates of over 80%. The latest DHS (2000) has reported a substantial decrease in immunization coverage rates, a 10% drop to 70%. One of the most important factors that has been suggested to be responsible for the drop is the role that the Health Surveillance Assistants (HSA) play in service delivery. In the past, most HSAs have been dedicated to support immunization services. Of late, however, they have been seen as the super health worker capable of doing everything at the community level. They are very often asked to implement the whole of the health sector plan at the community level. This apparently has taken the HSA away from supporting immunization services and may have resulted in a significant impact on immunization coverage. Furthermore, both UNICEF and the MoHP have, for some time, been planning to carry out an evaluation of the role, contributions and efficiency of the HSAs in service delivery, from a historical point of view.

Purpose / Objective

This study conducted an evaluation of the role, contributions and efficiency of the Health Surveillance Assistants (HSAs) in the delivery of health services, with particular focus on immunization and primary health care. The study, therefore, assesses the historical role of the HSAs, their origin, how their roles have changed over time and the impact that these changes have had on achievements in the health sector. Specifically, the objectives for the evaluation were:
- to explore the historical roles of the HSAs in the delivery of heath services
- to determine the effectiveness (quality and quantity of work) of the HSAs in the sector, with particular attention to immunization and primary health care activities
- to assess the working conditions and constraints against the efficiency of the HSAs work
- to assess the community's response to the HSAs
- to explore other health areas where the HSA can be utilized within the context of Primary Health Care, without necessarily putting additional strain on him/her


Salma District was purposively selected on the basis of its low immunization coverage rates as reported in the DHS report of 2000. A total of 61 HSAs belonging to 14 health centers and 325 mothers/female child caretakers from catchment areas of nine health centers were randomly sampled and interviewed. 60 extra HSAs were also randomly sampled and interviewed in Nkhotakota, Ntchisi and Dowa districts (20 from each) to provide a comparison.

Key Findings and Conclusions

The general picture rising out of this survey is that HSAs who were formally recruited as temporary Smallpox Vaccinators in the 1960s and as Cholera Assistants in the mid 1970s have contributed greatly to the delivery of preventative health services in rural areas of Malawi. Over time, they have formed an extensive network of ground staff bridging formal health services and the community. They are responsible for about 60% of all vaccinations that are given to under-five children in the rural areas. Their contribution has enabled the country to virtually eliminate and/or reduce prevalence rates of the highly infectious but preventable diseases namely: measles, polio, diphtheria, pertussis, smallpox and tetanus. They also play a very significant role in detecting disease outbreaks and in providing assistance to the victims.

The job description of an HSA is very comprehensive and has continued to change over the years as new interventions are introduced into the health sector. Currently, HSA tasks at community level include: child (and mother) vaccination, growth monitoring, sanitation, water source protection and water treatment, disease surveillance, village and business inspection, health and nutrition talks, and supervising traditional birth attendants and village health and water committees. Other tasks include providing family planning methods, implementing the Bakili Muluzi Health Initiative and the Drug Revolving Fund, following up on TB patients and other health-related tasks as advised by the government or NGOs.

In terms of time allocation, immunization, growth monitoring and health talks occupy over 40% of the total HSA's time followed by sanitation and water protection activities at 25%.

Most of the sampled HSAs (>30%) said that they enjoyed doing health talks and giving immunizations compared to TB work and HIV/AIDS talks. Tasks in which most of the sample HSAs reported to lack skills included disease investigation, family planning, water treatment, and administration of vaccines, particularly BCG and DPT.

On average, the sampled HSAs lived about 5 km from their health centers, although some lived more than 20 km away. The average population being served by the sampled HSAs was 2,364 people, but about 35% of them were serving more than 2,500 people (maximum of 9,500 for one HSA in the Salima district). The average distance to furthest villages for the sampled HSAs was reported to be 6 km, with the maximum being 17 km.

While the HSA network is very extensive and considerably old, findings from this survey have provided indications and evidence of undercoverage. Some sections in some catchment areas are not reached by the HSAs mainly due to accessibility and mobility problems, and not all HSAs are implementing all the tasks as contained in their terms of reference (TOR). Six of the 325 mothers sampled had never previously heard of, nor seen, an HSA. Sanitation, growth monitoring, immunization, family planning and health talks were cited by 60-88% of the sampled mothers while the rest said they had never heard of these activities being carried out in their villages, even after probing. This suggests that some pockets of households in the various communities are never reached by HSAs or that some tasks contained in the HSAs' TOR are not being implemented at all.

Most of the sampled mothers (>80%) who had interacted with an HSA before, applauded those HSAs very highly for the work they were doing. However, some mothers felt that the HSAs' performance was being affected because of the side effects of vaccinations, frequent shouting at mothers, boasting that they know more than villagers, irregular visits, infidelity and non-availability of drugs. Only 30% of the sampled mothers said that they had consulted an HSA before for some assistance other than immunization, growth monitoring, and health talks. Access factors accounted for 54% of all the reasons why some mothers had never consulted the sampled HSAs, followed by quality of service (21%), relevance (19%), and problems with scheduling (6%).

The survey also identified a number of constraints that are affecting the performance of HSAs in the delivery of health services. Common constraints that were cited included mobility problems (69%), poor remuneration, no promotion and low status given to HSAs in the civil service (84%), irregular supply of vaccines and drugs (65%) and lack of protective clothing and stationery (65%). At the time of the survey, only 5 of the 121 sampled HSAs had anti-malarial drugs, while 4 had antibiotics and 4 had pain relievers. On the other hand, condoms were available to 41 HSAs, child weighing scales to 59 HSAs and ORS Sachets to 33 HSAs.

In addition to the above constraints, most HSAs are untrained (19% of the sample) and supervision is inadequate and irregular. Furthermore, refresher courses are limited and irregular.

In general, overall support to preventive health services has been declining over the years and this mentality has trickled down to the district and health center levels where preventive services are given little attention. In fact, some resources, notably vehicles, were reportedly being diverted away to other sectors.

On immunization coverage, our findings indicate that over 80% of the 418 sampled children had received all the vaccines for which they were eligible. As such, coverage (in general) was not bad. The problem was with the timing; most of the children received the various vaccines very late. The findings, therefore, revealed a set of administrative and logistical hurdles to immunization work, mainly at a level above that of HSAs. These hurdles include lack of transport to carry vaccines, unavailability of some vaccines, non-functioning refrigerators and lack of paraffin, geographical inaccessibility especially during rainy season, high dropouts because of the side effects of some vaccines, and inactive Village and Health Committees. Other problems include incorrect scheduling of immunization sessions and cultural beliefs.


The overall recommendation being made by this report calls for increased support regarding training and technical support towards preventive health services, and reorientation of priorities in the MoHP so that infection and exposure rates are reduced.

To achieve these objectives, there is need for collaboration among various stakeholders (government, multilateral agencies, NGOs and the private sector) in terms of HSA training, development and provision of refresher courses and transport. As a way forward, there is need for the National Health Surveillance Programme to update records of HSAs in the country; i.e. their numbers, training status, and to insure proper mechanisms for monitoring and evaluation. The MoHP should revise its strategies on human resource development to incorporate the needs of HSAs.

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