Table 2

Overview of three PMTCT lay health worker models operating in Malawi

Expert ClientsMentor MothersTingathe-CHW
Expert Clients are recruited and overseen by several different non-government groups (EGPAF, mothers2mothers) and at least one District Health Office. In several districts, Expert Clients are no longer supervised by any organisation as project funds have run out. These Expert Clients work independently, relying on pre-existing relationships with MOH clinic staff and the community.Mentors Mothers were recruited and overseen by the non-government organisation, mothers2mothers.Tingathe-CHW are recruited and overseen by the Baylor Tingathe programme. These CHWs are distinct from Malawi’s cadre of government employed community-based public health agents called HSAs.
Recruitment and trainingRecruitment and trainingRecruitment and training
Expert Clients could be either men or women, who are living with HIV, are virally suppressed and open to others about their HIV status. They must be confident and willing to discuss their own experiences with HIV and ART in both group and one-on-one settings. There is no age requirement. Typically, Expert Clients were meant to have a Junior Certificate, although exceptions were made for highly articulate individuals, provided they could read and write. Expert Clients tended to be volunteers, sometimes receiving a monthly stipend. They usually received an initial training of about 2 weeks.Mentor Mothers are all women, living with HIV, who have been through the PMTCT cascade, so most of the mothers tend to be middle-aged. In order to be a Mentor Mother, a woman needed to disclose their status and be open to talking about living with HIV and living positively. All Mentor Mothers were required to have finished Form Four and be able to read and write. Mentor Mothers are recruited via advertisement and formal interviews by mothers2mothers staff. Prior to beginning their work, they undergo a 2-week intensive training workshop covering the MOH HIV guidelines, and all MOH tools and mothers2mothers tools.Tingathe-CHWs can be men or women, who may or may not be living with HIV. Although there is no formal age requirement, interviews and observations suggested the programme targets younger recruits due to the travel requirements (frequently on bike) of the job. Tingathe-CHWs must have a higher level of education compared with Expert Clients and Mentor Mothers, received 6 weeks initial training and ongoing quarterly updates. Tingathe-CHWs are required to live within the communities, so that they are ‘embedded’ and accessible community members. Tingathe-CHW are formal employees, and provided daily supportive supervision.
Activities and relationshipsActivities and relationshipsActivities and relationships
Expert Clients work in both the clinic and community setting. In the community, Expert Clients are mobile, and visit clients in their homes or other settings with no restrictions on the distances travelled. In the clinic, Expert Clients are technically supposed to be based in both the ART and ANC departments. However, interview and observational data suggest that for various reasons (space, staff dynamics and relative time demand), Expert Clients are more usually based in ART, and visit ANC on a need-dependent basis.Mentor Mothers play roles at both facilities and in communities. In the facilities, Mentor Mothers are predominately in ANC. They welcome women to antenatal and help women to navigate the different queues for those coming to antenatal for the visit time. Facility-based Mentor Mothers interact with all women coming for their first antenatal visit regardless of their HIV test result, providing pre-testing and post-testing support to all. While facility-based mentor mothers conduct home visits within a 5 km radius, some sites also have community-based mentor mothers, who work predominately in the communities surrounding the health facilities. The two types of Mentor Mothers work together, have linkage registers and have monthly meetings to ensure clients from the community are linked to the facility and vice versa.Tingathe-LHWs work in both the clinic and community setting. In the clinic, Tingathe-CHWs tended to have their own (NGO-funded) offices. In their support work, they are based predominantly in the ART clinic, although were observed travelling around all clinical/hospital departments where the study observations took place. Reflecting their educational status, Tingathe-CHWs were observed to take on a number of higher-order coordination-style tasks in the facilities they worked in. In the community, Tingathe-CHW are highly mobile, visiting clients in their homes or other settings and they do not have any restrictions on the distances travelled. Most Tingathe-CHW active in the community had received a bicycle, improving their reach and efficiency.
  • ANC, antenatal care; ART, antiretroviral therapy; CHW, community health worker; HSA, Health Surveillance Assistant; MOH, Ministry of Health; NGO, non-governmental organisation; PMTCT, prevention of mother-to-child transmission.