Table 1

HSAs and CHVs before Malawi’s community health strategy

Health surveillance assistants (HSAs)Community health volunteers (CHVs)
Terminologies and brief description
  • A health surveillance assistant is a state-paid, primary healthcare worker serving as a link between a health facility and the community

  • CHVs are “individuals who willingly offer their time, skills, and knowledge to work with communities to improve the health status of communities they reside in without expecting financial remuneration”

  • Some examples include volunteers in community-based/faith-based organisations (CBO/FBOs), community-based distribution agents, growth monitoring volunteers, peer educators, traditional birth attendants, sanitation promoters, representatives selected to community committees (such as village health committees)

Policy context (key timelines)
  • 1960s: government hires and trains volunteers as smallpox vaccinators

  • 1970s: government hires and trains volunteers as cholera assistants

  • 1998: government formally establishes HSAs cadre

  • 2014: HSAs’ task-shifting policy and guidelines introduced

  • 1980s to early 2000: informal caregivers provide home-based care (pre-antiretroviral treatment era)

  • 2005: introduction of a national palliative care policy and community home-based care (CHBC) guidelines. Policy focused on HIV and other opportunistic infections

  • 2011: revision of CHBC policy to place emphasis on care and support for other chronic conditions and vulnerable groups

Formal requirements (or other selection mechanism)
  • Have completed Malawi School Certificate of Education or Junior Certificate of Education

  • Can speak and write in English and Chichewa (national language)

  • Attend HSA pre-service training programme

  • Once hired, expected to reside in the same catchment area of communities they serve

  • CBO/FBOs are composed of lay volunteers living in the same community with people (clients) they serve

  • A desire to volunteer and work for communities

  • Other entry requirements are optional (gender, age, education level)

Basic or professional training
  • Undergo HSA pre-service certified training of 12 weeks (8 weeks class-based and 4 weeks practical)

  • May receive specialised training when new health interventions are added to service delivery packages

  • CHBC providers (including volunteers in CBO/FBO) receive training for 10 days using the national CHBC guidelines

  • May receive training offered as part of project-driven activities

Main roles (scope of activities)
  • 1998: HSAs expected to conduct health promotion, immunisation, disease surveillance, patient referral to care and community case management

  • 2005: HSAs support HIV care as part of task-shifting initiatives

  • 2010 onwards: pilot interventions on working with HSAs to support with mental health services and non-communicable diseases in some districts in Malawi

  • Other: responsible for supervision of other community-based groups

  • They offer a range of health and non-health support

  • CBO/FBOs thematic areas include: (1) HIV/AIDS care; (2) home-based care; (3) safe motherhood; (4) hygiene and sanitation; (5) elderly and disabled persons care; (6) orphans and vulnerable children care; (7) support community-based child care centres; (8) human and child rights; (9) youth; (10) gender; (11) environment/climate change and agriculture; (12) livelihood support through income-generating activities

Reporting lines (formal and informal)
  • Report directly to senior health surveillance assistants. HSAs’ post is under the Department of Environmental Health (Ministry of Health)

  • Works with and reports to other health worker cadres such as clinical officers and nurses, depending on assigned tasks

  • Beyond health facility level, HSAs work together with other community volunteers and groups, and local authorities

  • CBO/FBOs are registered groups with the Department of Social Welfare (Ministry of Gender, Children, Disability and Social Welfare)

  • Work closely and disseminate reports to various departments of health and social welfare office, and Ministry of Local Government and Rural development

  • HIV patient support groups are established and embedded within CBO/FBOs. Patient organisations like the Network of People Living with HIV/AIDS Malawi work with CBO/FBOs

Contractual arrangements
  • Permanent post, employed by the government (Ministry of Health) and receive a standardised monthly salary, with possibilities of job promotion

  • Not official, engage in periodic project-led activities and could at times receive a monthly stipend (non-standardised)

Forms of support or incentives
  • Receive a monthly salary, supported with other financial and non-financial incentives, for example, housing, uniforms, bicycles and motorcycles

  • Variable incentives (1990s to present day) ranging from provision of T-shirts, bicycles, stipends, home-based care kit supplies

  • 2005: national funding through the National AIDS Council to support civil society organisations and CBO/FBO programmes in HIV/AIDS activities

  • 2015: direct funding to CBO/FBOs from the National AIDS Council stopped