Thyolo Health Services, Malawi

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District health care workforce

The team at district hospitals comprises doctors, clinical officers (also known as clinical associates) and medical assistants who have three and two years of clinical training, respectively. Other cadres and allied health professionals are laboratory technicians, physiotherapists, dentists, pharmacists, eye specialists, environmental staff and other cadres.

The district health management team (DHMT) operates from the district hospital and includes clinical, nursing, environmental and administrative arms. The DHMT plans, monitors and evaluates the district health care activities as a whole. 

Health centres are staffed by nurses and medical assistants or clinical officers (mid-level practitioners). Nurses deal largely with primary maternal and child health services. Teamwork at the health centre level between clinical, nursing and environmental staffs exists, but only to an extent. There exists a fair amount of dichotomy in the implementation, monitoring and evaluation of the respective activities.

The community links with the primary care facility are via a team of health surveillance assistants (HSAs), community health workers (CHWs) and traditional healers. HSAs are a community level cadre who received 12weeks of initial health preservice training and ideally reside in the community they serve. Each HSA is responsible for about 1500 people, and there are currently about 500 HSAs in Thyolo district. HSAs mainly provide health promotion and preventive health care through door-to-door visitations and outreach clinics.  The clinician and nursing roles at the health centre are largely curative, with minimal health promotion and preventive responsibilities. Most of the said roles are taken by environmental staff (HSAs) and CHWs. This dichotomy is seen, for example, during outbreak management or immunisation campaigns, where HSAs take most of the responsibility. Community volunteers act as a conduit for community engagement with the local community leaders and health advisory committees.

In the community, HSAs are seen as ‘doctors’. Their roles extend from sanitation, health promotion and community diagnosis to treatment of minor illnesses, especially in hard to reach areas as part of integrated management of childhood illnesses programme. Within the community, HSA’s work through the village leadership and CHWs as a team. With current efforts on decentralisation, efforts are being invested to harness community involvement to collectively contribute towards solutions to improve primary care outcomes