Community Health Volunteer initiatives within national health systems

There is global consensus on the importance of community-based health workers and on consolidating the contribution of community-led health initiatives.7 10 16 Common generic terms for these workers are ‘community health volunteers’ or ‘community health workers’, which covers an array of individuals, selected through different mechanisms (eg, nomination, election and/or hired from communities), who receive basic healthcare training and fulfil a variety of roles within communities.1 7 17 Examples include India’s Accredited Social Health Activist,18 Nepal’s Female Community Health Volunteer scheme,19 Ethiopia’s health extension workers20 and other broad terms like lay volunteers.1 However, there is general acknowledgement that the roles and categories of these health providers are often blurred due to variable terms of engagement such as whether they are paid or unpaid, contracted as permanent or casual workers, have undergone accredited training and what recruitment mechanisms are used, including whether or not they ought to be residents of communities they serve.2 17 21

These are issues which, in the 1990s and early 2000s, led countries (e.g. Ethiopia, Kenya, Rwanda, South Africa, Zambia) to establish national community health policies and strategies.20 22–26 In some cases, additional guidelines were developed and scaled up to facilitate collaboration and task-shifting processes between professional and non-professional health workforce.3 23 The challenges encountered in this historical process have been considered in a number of studies.2 26–29 For instance, CHVs in some countries are often overlooked in government policies even though ‘on the ground’, they are known to liaise and/or work with formally recognised community health worker cadres, such that recently there have been recommendations for more inclusive policies.2 10 21 Furthermore, providing financial incentives for volunteers remains contentious; the threat to the longstanding ethic of voluntarism set against concerns about the inequity, in impoverished communities, of not compensating CHVs.30–32 While these challenges are not new nor unique to present-day health systems, they require solutions that align to the commitments declared in Alma Ata in 1978.33

Community healthcare in Malawi

Malawi, a southern-African country with 17 million people, has a three-tier healthcare system.13 34 That is, primary health (including community-level services), secondary and tertiary levels of care, linked through a referral system.34 In 1998, health service management was decentralised to district council authorities, who oversee planning, coordination and financing of health activities in their jurisdiction.13 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).36 37 HSAs’ recruitment criteria include secondary school completion and language competence, and on selection, individuals must undergo at least 12 weeks of pre-service training.37 38 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

Malawi’s extensive network of CHVs13 14 42 emerged largely in response to the HIV/AIDS shifting epidemic and directed by donor-driven project activities and global financing mechanisms for health (see table 1). Community home-based care programmes run by community-based/faith-based organisations (CBO/FBOs) offered health promotion, HIV testing advocacy, palliative care and home nursing for patients with HIV/AIDS through a volunteer workforce.14 42–44 In 2005, Malawi’s government introduced a community home-based care (CHBC) policy and guidelines, which set standards for CHBC programmes, and later revised in 2011 to incorporate care support for patients with other chronic conditions (such as cancer and cardiovascular diseases) and at-risk groups.43

Malawi’s community health strategy (2017–2022)

The strategy proposes formation of a community health team (CHT), consisting of frontline health staff (HSAs, senior HSAs, nurses and environmental health officers) supported by CHVs, in linking community and primary healthcare interventions.11 The strategy’s core principles and objectives are highlighted in box 1. Malawi’s transition to the proposed service delivery structure is anticipated to be a dynamic process with possible overlaps in key areas of service delivery, coordination and finance, which we highlight in the next section.

Potential dynamics, overlaps and friction in implementing Malawi’s strategy

Possible opportunities and recommendations for further strengthening Malawi’s community health strategy

While our analysis highlighted possible dynamics, overlaps and frictions arising from Malawi’s transition to a new service delivery structure, we also identified opportunities and current strengths to be further explored as Malawi’s strategy implementation scales up. Here, we reflect on experiences and lessons presented in the literature on community health.

First, the delivery of community-level EHP interventions through multidisciplinary CHTs requires a thoughtful as well as pragmatic streamlining of roles and matching of skill sets at team level. There is a risk that competency gaps may result in underserved areas within the EHPs and/or lower standards of care. As reported in earlier Malawian studies,12 35 36 there are genuine concerns over HSAs’ roles, which expanded over time against unmatched training support, and the expectation that they can deliver both community-based and facility-based activities as part of their job description. Experience from South Africa’s ward-based outreach team model suggests that while primary healthcare staff are expected to assume more community-based responsibilities, including leadership and clinical supervision to non-health professional team members, in reality, they tend to prioritise facility-based care given workload demands.47 The expansion of CHBC programmes in Malawi to include patients with other chronic conditions (besides HIV)14 has to a large extent been unsupported by capacity building in these areas. In a changing epidemiological context, there is a need for a well-trained health workforce sufficiently skilled to respond to the shifting healthcare demands within communities.7 While EHPs are structured around disease-specific programmes,11 training should preferably cut across all listed domains to minimise the risk of neglecting areas that have traditionally received the least form of support, such as community mental health. In the long term, the proposed development of a national integrated training manual for CHTs is critical.

Second, CHTs’ workload requires attention, particularly in the face of financial and operational difficulties to fill all team positions in the short term. Health managers/supervisors could consider mapping trained CHVs from existing networks of volunteer-led programmes (eg, CBO/FBOs) and assigning them to CHTs. CHVs could continue supporting health promotion and home-tracing activities since they are embedded in communities, while available HSAs could support outreach activities and other specialised tasks under community-level EHP interventions. However, experiences elsewhere caution against reliance of volunteers as substitutes/replacement for professional health workforce, while facing critical health workforce shortages.2 10 17 28 This could potentially exacerbate problems such as strained relationships between paid and unpaid personnel, undermining the value of volunteer work or raise expectations as volunteers hope for consideration into paid positions, which may prove difficult.2 30 For Malawi, an addendum to the strategy, outlining possibilities of task-shifting between CHT members, expected duties of CHVs and interactions with paid CHT personnel, is necessary. Clear reporting lines and supportive supervision are essential to make these arrangements work.

Third, the ongoing flux in financial and material support for volunteer-based programmes and the risk this poses for implementing Malawi’s strategy needs further deliberation. Much has been written about ‘voluntarism’ in healthcare delivery in low-income settings, how this can or should be supported, and by whom.1 2 28 30–32 Malawi is not an exception, and the existence of a large network of volunteers who provide essential support to a range of community-based interventions11 14 43 warrants discussions of how to absorb them under the new strategy. Over the years, CHBC programmes, and within them CHVs, have had to be resilient to interruptions in donor-funded and national HIV programme support, and to the absence of clear compensation mechanisms. District authorities and project partners need to deliberate on appropriate forms of support that respect and enhance the critical role of community-based structures and civil society in healthcare delivery. Options applied elsewhere in the region include development of a standardised costing structure for volunteer-led work, which takes into consideration workload, nature of tasks and opportunity costs, as illustrated by a Ugandan study31; or provision of non-financial incentives such as bicycles in remote settings, stationery support and other forms of recognition such as certificates.27 32 48

Fourth, the management of multiple actors in the community health strategy requires strong leadership from district health systems. In the early implementation phase, mobilisation and sensitisation of all actors and structures within the community health system is paramount. Strategies to strengthen coordination include building on existing forums, reinforcing the role of technical working groups, and identifying avenues for communication and dissemination at community and district levels. For example, in the study district, monthly forums to discuss CBO/FBO issues were organised with representatives from social welfare and district AIDS coordinator’s office. The experience of community health policy implementation in Kenya illustrates how community health structures were reformed on a large scale.24 27 The process was spurred by decentralisation of governance functions to subnational level and realignment of coordination structures to fit with stipulations of a revised national constitution.

At national level, updated guidelines and harmonisation of policies allied to the community health strategy, and their subsequent dissemination is necessary. While Malawi’s strategy is directed towards unifying multiple actors and sectors working on health, Rwanda’s ‘One Health’ approach49 exemplifies an attempt of forging close collaboration across sectors/disciplines, guided by a single strategy and pooled funding, to integrate approaches to manage various determinants of animal, human and environmental health. Financing Malawi’s strategy therefore requires joint efforts between district authorities, development partners, private sector and central government to pool funds and ensure sufficient allocation for community health activities. In particular, it is crucial to ensure that EHP interventions are constantly available in order for communities to receive appropriate care when needed.

Moving forward, further evidence is needed which explores how the proposed accountability structure is functioning at multiple levels; document actual experiences within CHTs on work performance, job descriptions and support structure; and EHP interventions delivery and cost–benefit analysis of implementing this strategy at scale. This evidence is necessary as Malawi and other countries in the region pursue the synergies between public, private and civil-society investments in community health.