Primary Health Care (PHC): Fantasy or reality for Malawi

From the recent political blog, I am back to my senses after sobering up and ready to report on more community work. Today I am writing about Primary health Care, PHC in short.

There is a long definition of what PHC is supposed to be as given by World health Organisation: (WHO, Alma Ata Declaration. WHO1978 p.3-4) that includes 5 sets of principles, viz: affordable and sustainable health systems development, appropriate(user friendly) technology, intersectoral collaboration, community participation ,and equity to access of services –whatever these mean!!! “Remember the Health for all by the year 2000” this was one of the WHO initiatives that was going to use PHC.
Heard about Millennium development goals (MDG’s) - most of these need PHC to be achieved.
So why is an eye doctor in the forefront talking about PHC? Well, for your information we are supposed to be integrating primary eye care (PEC) into Primary Health Care (PHC).There is now renewed call by “WHO” for implementing PHC in developing countries.

But how are countries like Malawi doing on PHC at grassroots level? This is a political question so need to be answered by politicians; but I will only be giving my views based on my experiences with the communities mainly in Southern region of Malawi. For this blog I will concentrate on my experiences during my recent visit to Mangochi district.
Fact 1 : Health Surveillance Assistants (HSA’s) are the main provider of primary health care in all communities in Malawi .I was introduced to this group of workers in 2007 when I started my research in eye care and since then I have interview over 200 HAS’s and trained about the same number on primary eye care. They fall under two levels of employment by the Government; those employed before 2007 –referred as normal HSA’s and those after July 2007,referred as the Global HSAs’s (because they were deployed under the global fight against HIV/AIDS initiative).They all are supposed to undergo a 10 week orientation training in everything (preventive ,curative and rehabilitative services) and then attend other on-job trainings .
Fact 2: At most 50% of all HSA’s recruited in 2007 have not after 2 years formally attended their 10 week training in Mangochi, Zomba and Mulanje and are actively doing their day to jobs without training .
Are we sure these personnel are doing what we intended them to be doing? Are they doing standardised procedures?
Fact 3: Some of the health centres with a catchment area of higher than 10,000 persons have no medical assistants, or nurses and are left to be taken care by HSA’s who attend to and treat all sorts of patients including maternity patients . I witnessed this in Mangochi at a health centre I visited to screen blind children , I was told there was neither a nurse or medical assistant there ,the senior HSA was in charge and was doing all the clinical work (and he was staying in a beautiful institutional house that would have been used by the nurse of she were there)
Can these HSA’s treat patients even if they were trained for 10 weeks? Is this what PHC is for Malawi –HSA’s taking place of medical personnel?
For once they are not recognised and registered by any nursing or medical body in Malawi ,yet they are doing what they are not supposed to be doing .Is this what PHC is all about ?
In my view one cannot be qualified to offer medical treatment when they are only high school (secondary) leavers and have only attended 10 weeks orientation.
Fact 4 : the Maternal mortality (number of mothers dying in child birth) for Malawi is the highest in the world ; the same non trained HSA’s are supposed to be in the forefront in preventing these deaths.
Are you surprised therefore that the numbers of mothers dying is not reducing in Malawi (unless we start cooking up the figures so that they shrink)?
These HSA’s are underpaid, have poor skills and are not clinically supervised. They can only be motivated to do best by improving these?
PHC is supposed to be strengthened at grass root /community level; this is definitely not the case in Mangochi. I visited some health posts and health centres in Mangochi where they had not had any supervisory visits from the district hospital since the start of this year. In another busy health centre, I found an intern (trainee medical assistant ) running the hospital after being posted there 8 months ago; he told me he had never been supervised or told what he should exactly do.
Unless our leaders invest wisely in PHC in Malawi; we are doomed to fail.

Remember “Failing to plan is planning to fail”

Those who believe and say that we are achieving a lot through PHC should go and spend time in the communities and witness what is happening there; we may be making some progress , but some of us have collected figures that prove the contrary .Show me your statistics ,and I will show you mine. I was very optimistic about PHC when I started my research, now I have become pessimistic.
Do you more data from me?
Do you want to debate?
Or do you want just to comment?

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Check for my next blog? Which MDG’s can be achieved by 2015 in Malawi?

Facts about Community Health workers in Malawi

Health surveillance assistants (HSAs) implement the bulk of community health projects in Malawi; and they do a good job if trained properly and given the appropriate incentives . I can help in organising such trainings if need be.

Challenges involve motivating them to continue doing the work in the community; and providing adequate supervision.
In Zomba district, one particular group that we trained did extremely well in identifying many children from their communities with eye problems.

There is a World Health Organisation document which talks about guidelines for incentives for health workers, and I am currently studying it to find out which ones can be available to motivate the HSA’s

Without HSA’s ,I believe the health system at community level would collapse in Malawi .But can HSA’s do everything and do it well? Have you heard about Task shifting? If not ,that will be the subject of my next blog. Have a good day.

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Oops!!!! Disaster in training HSA’s in Mangochi

Are you involved in training Health Surveillance assistants (HSA’s) in health projects in Malawi? Do you have evidence based facts of their success in implementation after training?

I have just returned Mangochi where we trained a group of 30 HSA’s from Mangochi Zone and another group of 30 volunteers from Chilipa Zone where I faced major challenges with the HSA’s .Relax and I will share my experiences with you.

Having trained HSA’s in Mulanje and Zomba (a total of over 300) I thought with my vat experience, the training in Mangochi would be smooth. I had overlooked a number of issues which I would advise any one willing to train HSAs in Mangochi to seriously consider before rushing doing anything. Mangochi district ,in Southern Malawi is 190 km from Blantyre and has the beautiful Lake Malawi on one part of it and lake Malombe on the other. Lake Malawi has various tourist resorts and Hotel and the environment is very friendly .I stayed at the mini Martins Lodge
The district though very rural has various health research projects including the College of Medicine department of community Health and the Malawi Liverpool Welcome Trust. Most of the community projects involve training and using HSA’s

HSA’s take the invitations to attend the trainings as a privilege and look forward to the financial incentives that are associated with the training.
Some HSA’s claim from Mangochi that in order to win to win their favours and loyalty some NGOs pay them an allowance of up to USD 50 per day despite the government lunch allowance being USD 7.

We thought we had done our assignment well ;had talked to the responsible officers and agreed we would give an allowance of USD 7 for the one day training but in addition we would provide drinks and snacks .As a background in 2007 I had done a situation analysis in Mangochi on why HSA’s despite working in the community were not involved in identifying children with eye problems .I spoke to a group of representative HSAs (20 in total) and they all indicated what they lacked was the skill and if trained they would be willing to do such a job. So this training was organised as part of my study and in response to the findings .We conducted the first training to a group of 30 Volunteers from a different area on day one ,gave them the allowances and snacks. During day 2 we arrived at a different place to train HSA’s ;started the training but noted that the participants were not attentive. In probing why ,we learnt that they wanted to know how much money they would get at the end of training ,and whether we had brought t-shirts and other incentives for them. After explaining that we would only give USD 7 as per what volunteers got the previous day, the whole workshop turned into chaos with the HSA’s threatening to boycott the training and forfeit the highly needed skills if they did not get all their monies .

So how did it all went at the end ? Not very well – I sustained a few emotional bruises .I would like to write a whole blog about this –when I am better.
For now you can gues!!!!


Have you experienced difficulties in conducting training? What did you do? Or are you just interested to comment.

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Primary Health Workers for Malawi

If you are an NGO or an individual interested in community health issues, you probably be wondering how much impact the role of community health workers have in improving the health of Malawians. In particular to this cadre are the so called Health surveillance assistants (HSA), who are said to be the backbone of the health system in Malawi .HSAs are employed and paid by the Ministry of Health. But what skills do HSA’s have to implement health care; and if trained do they actually do their work.
There are currently an approximately 12,000 HSA’s in the Malawi public service ,as a result of the recent scale up (2007) with almost half employed by the ministry of Health under the Global fund and other funding parteners and the rest through normal employment. HSA’s are responsible for implemented most of the health initiatives in the community, and for disease surveillance .By education ,the newer HSA’s have reached at least high school (Form 4) ,while the order groups may have not been very educated .HSA’s only undergo a 3 months training in Preventive, Diagnostic and Curative measures and upon completion they become experts in all community diseases .
With all the community interventions in Malawi relying on HSA’s ;is there evidence that HSA’s have contributed to the reduction in morbidity and mortality of the common Malawians .What are the implications and limitations of using HSA’s in health programmes ?

A look at the maternal, mortality figures in Malawi indicates that Malawi has the highest mortality rates (1120deaths per 100,000 mothers delivery) despite the many health promotion messages being spread by HSA’s. Many causes of these deaths are attributed to low levels of maternal care.

Unicef States of the world children 2009 that over a period of 16 years (1990 and 2006) of intensive community programme interventions, Malawi has only managed to reduce under five mortality by 40% and that the main causes of deaths still remain preventable at the community level. HSA’s are taught the integrated management of childhood infections (IMCI).
Since 2007 I have been involved in training HSA’s in identifying blind and visual impaired children in rural communities in Malawi; and have been comparing their performance with a matched group of trained volunteers .
I have very interesting results –which will be published later ,but certain issues desrve to be mentioned at this stage.

I have noted that most NGO’s and government institutions assess the outcomes of HSA’s training through reports submitted to the interested parties ,and that rarely do the trainers observe and access the skills attained by HSA’s after the training. I have also noted that most HSA’s rate the trainings based on the amount of subsistence allowance received during the training, and not on the skills attained. The mismatch in expectations between the trainers and the HSA’s has more than often resulted in not having proper measures to measure the outcomes of trainings .
In my next blog I would like write about what incentives HSA’s have mentioned to be being necessary for them to do the work ; and whether when given such incentives they have successfully accomplished the desired tasks. I will also be introducing the tracking tools that we have developed to assess whether HSA’s are doing their work and the incentives that we give. In the picture I am listening to a group discussion by HSA’s from Zomba. The forms we have devised can be used for any time of training and I will be more than willing to share with you.

Are you involved in training HSA’s in health projects in Malawi? Do you have evidence based facts of their success in implementation after training?

Or do you want me to share our results with you? Or are you just interested or want to comment.

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Jali , Zomba

Today, we have been privileged to be conducting out training for community Health workers (volunteers and health Surveillance assistants ) at Jali epicenter in Zomba districts. I am with my team as usual ,Frank Mbewe, Ruby Ngongola and Mr Munthali from Zomba Central hospital eye department .The road to Jali used to be very bad but now its all tarred and it takes only about 30 minutes from Zomba towm.
There is so much happening in the field that I wish I had time to write about everything, but this time its not possible. Just imagine yesterday I was stuck in the mud with the car for over two hours until a group of well wishers pulled me out .
We have been to Chingale , Chipini, Mayaka , Ngwelero, Lilkangala and so far we have trained over 120 eye health workers.
Next week we start screening the children the trainees have identified .
I am officially travelling from Blantyre to Zomba (60 km) and returning on a daily basis .
You can see me standing and the partcipants eating while the classroom lecture is going on.

Have you been to Jali? Do you want to know how to get there ? Do you just want to comment?

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