Motivation of health surveillance assistants in Malawi: A qualitative study

Abstract

BackgroundMotivation of health workers is a critical component of performance and is shaped by multiple factors. This study explored factors that influence motivation of health surveillance assistants (HSAs) in Malawi, with the aim of identifying interventions that can be applied to enhance motivation and performance of HSAs. Methods A qualitative study capturing the perspectives of purposively selected participants was conducted in two districts: Salima and Mchinji. Participants included HSAs, health managers, and various community members. Data were collected through focus group discussions (n = 16) and in-depth interviews (n = 44). The study sample was comprised of 112 women and 65 men. Qualitative data analysis was informed by existing frameworks on factors influencing health worker motivation. Results Our analysis identified five key themes shaping HSA motivation: salary, accommodation, human resource management, supplies and logistics, and community links. Each of these played out at different levels-individual, family, community, and organisational-with either positive or negative effects. Demotivating factors related primarily to the organisational level, while motivating factors were more often related to individual, family, and community levels. A lack of financial incentives and shortages of basic supplies and materials were key factors demotivating HSAs. Supervision was generally perceived as unsupportive, uncoordinated, and top-down. Most HSAs complained of heavy workload. Many HSAs felt further recognition and support from the Ministry of Health, and the development of a clear career pathway would improve their motivation. Conclusions Factors shaping motivation of HSAs are complex and multilayered; experiences at one level will impact other levels. Interventions are required to enhance HSA motivation, including strengthening the supervision system, developing career progression pathways, and ensuring clear and transparent incentives. HSAs have unique experiences, and there is need to hear and address these to better enable HSAs to cope with the challenging conditions they work in.

Care for Child Development in rural Malawi: a model feasibility and pilot study

“…In each district, HSAs are employed to conduct a wide variety of health task and roles for all members of the community. 13,14,34 In our study, the number of children under the age of 2 in all our areas covered by the six HSAs amounted to 420, roughly seven times the population that the HSAs demonstrated they could manage when asked to conduct groups in real-life settings in Malawi. Our findings indicate that due to the high existing workload of HSAs it is not feasible for them to actually conduct individual CCD visits and groups for every child under age 2 in their catchment area.…”

“…Many HSAs are overstretched and have difficulties in balancing demands placed on them. 13,14 HSAs have 12 weeks training. Some supervision by senior HSAs does exist but is not incentivized or competency based.…”

Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries

“…We have not presented data on the individual improvements achieved by the 29 improvement teams included in our study, which are similar to those observed by other community QI projects from several settings in sub-Saharan Africa 31–34 61–65. Immediate process outcomes of the QI approach we used included: improved supervision and integration of the community health programme to the health system, consensus building across levels of the health system on priority problems and improved data quality on critical health service areas—all of which have been shown to support improved performance of CTC providers 5 9 43 66 67. The health impacts of integrating QI are harder to attribute due to the complex, iterative and locally driven nature of the approach.…”

Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi

“…Nonetheless, in a country where over 80% live in rural areas, Malawi has depended on community-level health workers for many years. For instance, in the 1960s–1970s, volunteers were hired to serve as smallpox vaccinators and cholera assistants 13 35. Absorption of such volunteers into the national health workforce came to fruition in 1998, when Malawi officially created the health surveillance assistant (HSA) cadre as a permanent post (see table 1).…”

“…At present, HSAs constitute more than one-third (over 9000 employees) of Malawi’s health workforce, performing a broad range of tasks that include health promotion, immunisation and disease surveillance 34 38. Existing evidence documents how HSAs’ roles evolved overtime, their performance towards achieving health goals and job-related challenges 12 35 36 39. Recent evidence shows HSAs’ gradual support to facility-based tasks for non-communicable diseases (NCDs) and mental health services 40 41…”