Frontline Vaccinators and Immunisation Coverage in Malawi

Abstract

Access to health services for the poor, especially in the Global South, is a major challenge to achieving health targets like those under the millennium development goals. In Malawi, health surveillance assistants (HSAs) have been instrumental in bringing health services, including immunisation, to remote areas amidst an acute shortage of professional healthcare workers. On the basis of ethnographic fieldwork and historical sources, we describe and analyse the roles played by HSAs in delivering immunisation in Malawi. As frontline vaccinators, HSAs work under adverse conditions with low remuneration, rare upward career mobility and inadequate equipment. All the same, HSA immunisation services are generally considered satisfactory by supervisors as well as by caretakers/mothers among the local population. Without adequate resources for the supervision and continuous training of HSAs, however, the quality of immunisation and other services may be compromised. Unlike professional healthcare workers like nurses and doctors, HSAs undergo only limited training and can be easily replaced. Such a situation makes them vulnerable, a scenario which throws up a cruel paradox: in the HSAs' vulnerability lies the key to the health system. Amidst high unemployment and poverty levels however, the admittedly low salaries help to retain HSAs and enable them have a better life than most Malawians who live below the poverty line. The Malawi case demonstrates that, rather than relying on unpaid volunteers, community health work can be sustainable if the workers have a secure salary mainstreamed within the public health sector.