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The people's doctor

© UNICEF Malawi
In Malawi, one in every 13 children dies before their first birthday and one in seven will not make it past thier fifth.

“Good day doctor”, say villagers with warm smiles as Blessing Mwareya trudges up a stony track, looking smart in his light blue uniform, in the southern Malawian district of Phalombe.

His destination is a small mud home with a grass roof set on a hill near the stunningly beautiful Mount Mulanje. His patient, three-year-old Joseph, is seated outside on a mat, leaning against his mother. Although Joseph looks lethargic, he has made a dramatic recovery.

“Three days ago, he had a high fever and was vomiting,” says Kathleen Ephram, a single mother of six, two of whom are under five years. “I carried Joseph to the doctor's home.” It was a ten-minute walk, much nearer than the health centre which is 10km away. Moreover, Ephram did not have to wait for hours, as is customary at the overcrowded health centres. She was attended to right away.

Assessing Joseph's symptoms, Mwareya diagnosed malaria and immediately administered the first dose of an anti-malarial drug. Joseph's mother took the other dose back home to administer at a prescribed time. Ephram, who has never been to school, feels lucky this time round, having previously lost two of her children to malaria.

In Malawi, one in every 13 children dies before their first birthday and one in seven will not make it past their fifth. These children die mostly at home from diseases that, like malaria, are preventable and curable. Other main child killers are neonatal diseases, diarrhoea and pneumonia. Half of all child deaths are nutrition-related.

These tragedies could be prevented simply and cheaply by people like Mwareya, who is not a doctor, but part of a cadre of 11,000 health extension workers commonly known as Health Surveillance Assistants (HSAs). Already holding a secondary school-leaver's certificate, Mwareya underwent 11 weeks of training in the integrated management of childhood illnesses (IMCI), which emphasises treating the child in a holistic way and not just focusing on the illness. Thus the home – where most children die - is a key place to start.

Mwareya makes house-to-house visits, teaching the community about good childcare practices such as exclusive breastfeeding, use of long- lasting treated mosquito nets, hand washing at key times, and ensuring a clean environment. And if a child gets sick, he has a stock of basic remedies like oral rehydration salts, anti-malarial drugs, and cotrimoxazole, an antibiotic to prevent opportunistic infections.

© UNICEF Malawi
Mwareya welcomes patients to his house at any time of the day or night. “They say that I'm their doctor,” he says proudly.

If necessary, he knows when to refer a child to a hospital. The HSA programme is also complemented by monthly health outreach activities, where nurses from the health centre join the HSA to carry out a variety of crucial health activities. These include vaccination, weighing, deworming and distributing long-lasting mosquito nets. Micronutrients such as iron, vitamin A, folic acid and iodine are also administered.

The HSA's work is carefully monitored by the village health committee which is composed of an equal number of men and women and serves for three years. Dixon Malefula, a father of ten, is the secretary of the village health committee and says that the HSA is making a big difference in his village. “The death of our young ones has reduced in this village since the HSA has been working here.” He also lost two of his children in 2005 and 2007. “They had fevers. They would have been alive today had we had this health system then,” he says emphatically. Malefula's job is to keep a record of the drugs given to HSAs and monitor their use. “They are administered well,” he adds.
The District Health Officer, Raphael Piringu says the HSAs have been critical in reaching remote areas and populations where literacy levels are low. However, he says more visual materials, like flipcharts, are needed to boost health education outreach.

Piringu says diarrhoeal diseases have gone down and the district had not recorded a single case of cholera in two years. Malaria and HIV are still major problems and have even taken their toll of the HSAs. Out of the 279 HSAs trained, 11 have died of an HIV-related illness or malaria. There were already too few HSAs for the district of just over 322,400 people. And over half of them have to cover vast distances over hilly terrain on foot, as there are not enough bicycles for all of them.

Mwareya does not complain though. He takes pride in his work and says that although his official working hours are from 8.30am to 5pm, he welcomes patients to his house at any time of the day or night. “They say that I'm their doctor,” he says proudly.



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