Task Shifting and its Effects on Health Surveillance Assistants in Malawi

Introduction: Published literature suggests that task shifting is a very affordable way of providing health services in resource constrained settings. However, there is less empirical evidence on its effects on the mainstream tasks and workload of the cadres to whom the tasks are shifted. This thesis examines the consequences of delegating HIV testing and counselling services to Health Surveillance Assistants (HSAs) on their community work, workload and motivation in Malawi. Methods: Client records for Pentavalent, family planning and HTC for the period 2006-2010, when task shifting using HSAs just started, were collected from eight health facilities in Salima and Mangochi districts. Semi-structured interviews with 243 HSAs and in-depth interviews with 12 managers at national, district and health facility levels were also conducted to get their views and experiences with task shifting. Quantitative data and qualitative data were analysed separately and then later triangulated to identify recurring patterns and areas of commonality and discrepancies. Key findings: In 2007 when HTC task shifting using HSAs started, PHC and HTC services scaled-up especially at the facility and district levels. However, at the individual HSA level, PHC delivery declined arising mainly from high workload, difficulties with managing competing tasks and other health system challenges. Even though successful in service scale-up, the arrangement did not satisfy most recommendations by WHO on implementing task shifting and the success could be attributed to historical task shifting in the Malawi health sector. The HSAs reported facing challenges, common to the Malawi health sector, including long distances to catchment areas; large catchment populations, mobility problems, high workload, difficulties to schedule activities and unclear career path and low remuneration. Conclusions: Task shifting led to service scale-up in 2007 but mainly at the district and facility levels which may not have translated into similar improved PHC provision at the HSA catchment area level as the HSAs were grappling with many challenges which were affecting their motivation and job satisfaction. To sustain the success with task shifting, it may be prudent to provide more support to the HSAs, increase their numbers and consider some form of incentives.