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HSAs nightmare of toil but no credit

By Yohane Symon

They are the bedrock of Malawi’s healthcare system, but for all their immense contribution to the nations health, Health Surveillance Assistants (HSAs) are suffering some of the worst conditions of service in government, The Sunday Times can report.

For a week, we interviewed HSAs in Mangochi and Machinga and monitored how they are discharging their duties in different locations.

Our intention was to establish what they go through to assist people who are living in hard to reach areas.

We have established that their career has no direction as some of them have stayed at a single position for 23 years without being promoted or moved. While they are overworked, they are underpaid in comparison with the work they do to keep Malawi healthy. And while nurses and doctors are recognised and remunerated accordingly for their work, HSAs are left out on incentives despite providing equally critical services.

According to the Ministry of Health guidelines, a single HSA is supposed to have a catchment area of about 1000 people. However, in our investigations we have found that some HSAs are covering an average of six villages, translating to about 5000 people. And while they have a vast area to cover in their work, many of them struggle to move from place to place to discharge their duties within their villages.

Many of them have to walk, while a few rely on hiring bicycles or motorbikes.

“We were promised [by the government] that we will be provided with bicycles to ease our mobility challenges but up until now we are yet to receive them. Some of us were last provided with the bicycles about seven years ago,” said one HSA from Machinga District.

Apart from mobility challenges, the HSAs are also challenged with lack of uniforms, stationary and other personal protective equipment.

Most of those we have spoken with said their uniforms are worn out. Only medical personnel known in some of the remotest areas such as Makanjira, Katuli, Chilipa in Mangochi as well as Ngokwe, Nkoola and Sitolo in Machinga, the HSAs are the only medical personnel who people know and turn to when they need medical attention.

Their daily assignment includes working with traditional leaders to enforce bylaws which ensure that every household has a toilet, hand washing facility and proper kitchen.

On a weekly basis, the HSAs have to move house to house to monitor if households are following hygiene standards which the government promotes.

“We are also supposed to help patients with chronic diseases such as TB, Cancer, and HIV and Aids. But we are not provided with transport, allowances or even protective clothing. But when nurses and doctors visit the villages to do the same tasks they draw allowances from their DHO,” said an HSA who refused to be named.

After struggling with their work, the HSAs go back to houses which are dilapidated, complained another HSA.

“Our colleagues like nurses and doctors are provided with government houses, but we are not. We have to look for our own accommodation in areas where there is no potable water and electricity. It is even hard to find a decent house for rent,” she said In addition, the HSAs we spoke with indicated they are poorly remunerated despite their hard work to provide primary healthcare on which the successes in the country’s health hinges.

From our findings, most of the HSAs are paid between K80, 000 and K120, 000 gross per month.

Covid-19 injustice

With the current Covid-19 pandemic, the HSAs from Mangochi were each tasked to look after a Covid-19 patient in their localities before referring them to hospitals if the condition worsens. However, the HSAs who were assisting Covid-19 patients in their homes have not been drawing any allowances like the way other medical personnel do when they work at an isolation room.

“Nurses and doctors who are working in isolation rooms get allowances when they finish their shift. In addition to that, our friends are booked in lodges to quarantine for 14 days [after work in isolation wards] but the authorities are not doing the same with us and we risk our lives and those of our children,” said our sources among the HSAs.

On Tuesday we sent a questionnaire to spokesperson for the Ministry of Health, Joshua Malango, for their response on these issues. On being reminded, he said he had forwarded the questions to the Principal Secretary for response.

There was still no response as we went to press yesterday evening, despite several reminders and assurances of response.

‘Government should invest in HSAs’

But in an interview, Maziko Matemba, a community health ambassador appointed by the ministry itself, urged the government to invest a lot of resources in motivating the HSAs if Malawi is to achieve its objective of reducing the number of cases that are treated in public hospitals.

He said over 60 percent of infections that are treated in public hospitals can be prevented if the government emphasises on empowering the HSAs who are very crucial in giving primary health care in the country.

“It is very unfortunate that most of HSAs do not have what they require for them to effectively discharge their duties. As a country, we need to take advantage that the HSAs are already available in most parts of the country; supporting them with resources can double their output,” he said.

Matemba said while the United Nations is pushing countries to achieve Universal Access to health services, Malawi can utilise these community health workers to quickly achieve the goals.

How they came about

According to government records, the emergence of smallpox in Malawi in around 1950s moved the government to increase medical personnel who could help in providing primary care and vaccination to people affected by the pandemic. The outbreak overwhelmed the health system such that government had to engage temporary health workers to help in providing vaccine to affected people.

At the end of the pandemic, government decided to maintain the temporary workers so they could help in the provision of primary health care across the country.

Over time, they changed names from Public Vaccinators to Health Surveillance Assistants.

According to the government, HSAs support about 70 percent of the country’s 18 million most of whom leave live in areas which have no direct access to any health facility.

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