Primary Health workers: Is Quantity better than Quality in Malawi?

Am no politician, but Health is politics, and if you are interested in health issues in Malawi then follow discussions and debate below.
How often do researchers aim to publish findings from our findings from studies in Malawi in top journals /magazines like the “New York times” ,“British Medical journal” ,"The economists” and many others ? Well not many Malawians have access to such papers and may not even read about issues affecting them.
This is why I am publishing our preliminary research results on this blog, hoping that a few people interested in Malawi will read the whole article.

I am trying to design methods/ways of how primary health care workers can be used to find blind and visual impaired children in the villages early and bring them to our hospital for surgical intervention .Health surveillance assistants (HSA) are the lowest cadre of health workers in Malawi and most of their work involves working in a community surrounding a Health Centre .In 2007 there were about 6,000 HSA’s in the whole country (1 per 2,000 population).Within the last 3 months the Ministry of Health through a grant from Global Fight for TB , HIV, and Malaria have almost doubled the number of HSA by employing another ?6000 (no one knows exactly how many more but this number is supposed to have been achieved) on a temporary basis.

Is it a matter of increasing the numbers or improving the quality of performance of the existing ones? To answer this question lets discuss what HSA’s do in the health system in Malawi?

HSA’s are the first level of contact with the patients in the community and they are supposed to give health promotion (HSA were first recruited in Malawi for Cholera prevention programmes), but unfortunately currently they do a lot; give immunisations to children, treat fever in children, treat pneumonia, malaria, supervise patients on TB and ARV, give support to home based care, implement NGO’s programmes and many other duties. Talks about them whether being qualified to give ARV’s have been debated with no consensus reached.
HSA’s only undergo a 3 month short training medical course and currently they need to have a certificate (MSCE/JCE) to be accepted for the course. After graduation they become experts on every disease in the community and are supposed to offer primary health care (first level care) and then refer difficulty cases.

Well my Research Team last month (January) conducted Focus Group discussions (FGD) in 3 districts in Southern Malawi interviewing 30 HSA’s on what they know and do about eye diseases .We started in Mulanje (Chisitu and Chonde health centres), and then went to Mangochi (Chilipa and Nkope and Namwera Health centre, 40mKm from Mangochi Boma,), and finished in Chirazulu (Monfort /Nguludi Health Centres).

What did we find?
Almost half of the HSA’s at health centres were new having been employed with the last 3 months. They had not attended any form of training and they did not know when they would go for the 3 months course. Most of the old HSA’s had been trained, however surprisingly some of the HSA had not been formally trained 2 years after they started they job (work was all learned on the job).
Concerning Eye care both the old and the new HSA did not know the causes of eye diseases and how to treat or prevent them .The trained ones indicated that the 3 months course did not cover any eye diseases. There was no difference in the level of knowledge of eye diseases between the trained and untrained ones .Asked what they do when they see eye patients in the community, most of them just gave any eye drops available.
More than 50% of HSA’s believed that traditional herbal medicine can be used to treat eye conditions, and reported knowing either a relative or themselves using herbal medicine .The herbs used mainly in form of powder or eye drops included pepper leaves, green tomato leaves, fresh urine from patient and mothers expressed breast milk. Two HSA had personally used these herbs for treating their own eyes.

All HSA’s admitted to seriously needing some form of training in primary eye care and plans are underway to train some of them hopefully starting by June.

We did not deeply access the HSA’s knowledge and performance on other diseases.

Conclusion
The numbers of HSA has indeed drastically increased in Malawi but their quality of performance in eyes diseases is very poor.
Massive training and evaluation programmes are needed to assess future impact of HSA on eye diseases and further research is needed to assess their knowledge and performance in other diseases.

Research funds provided by International Centre for Eye Health London

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