Overview of Research Methods:
From 8–27 March 2022, a Malawi-based research team conducted 36 semi-structured interviews in six districts, purposively selected to include a mix of rural and urban areas with high and low immunization rates, with two districts from each of the three regions of Malawi. We conducted interviews with 15 HSAs, 6 HSA supervisors, 12 community members and 3 officials from the MOH or nationally represented partner organizations involved in immunization. Interviews were conducted by four bilingual Chichewa/English speaking researchers in either English or Chichewa depending on the preference of the interviewee. All interviewees were asked for informed consent prior to beginning the interview.
Table 1
| # of interviews conducted |
Partners | 1 |
HSAs | 15 |
HSA supervisors | 6 |
Community members | 12 |
Total Interviews conducted: | 36 |
All interviews were audio recorded, transcribed and translated into English (when conducted in Chichewa) by professional translators. All identifying information was removed from transcripts. Translations were reviewed by TC, a bilingual Chichewa/English speaking researcher. We used a deductive/inductive coding process, first creating an initial codebook based on topic areas from the interview guide, then adding additional codes when gaps were identified during the coding process. A team of three coders (RA, JP, and EG) conducted primary and secondary coding of four initial transcripts using Atlas.ti 8 and reviewed these for intercoder agreement. Transcripts were then divided and assigned to coders to individually primary code, with a secondary coder reviewing and adding only when requested by the primary coder. Reports were then generated according to topic area and each coder was assigned 2–3 reports to review and summarize. All authors reviewed the summaries by topic area, and key takeaways were identified and agreed upon through discussion.
Malawi Immunization Context:
The primary government-employed CHWs in Malawi are known as health surveillance assistants (HSAs). The HSA program in Malawi began in the 1950s with HSAs serving primarily as vaccinators. Malawi has steadily increased HSA responsibilities over time; HSAs’ tasks now include administering routine immunizations, infant and child growth monitoring, providing health education, promoting sanitation, promoting Vitamin A supplementation, assessing and treating children with common illnesses, conducting home pregnancy and post-natal visits, and administering oral and injectable contraceptives, among other responsibilities.11 HSAs are full-time CHWs and receive salaries on the government payroll. HSAs are unique amongst other CHWs around the globe because they serve as the principal vaccinator cadre in the country and are responsible for administering the majority (an estimated 80%) of routine vaccinations in Malawi, along with COVID-19 vaccines.12 Malawi’s immunization program is one of the most successful in the Africa region, consistently sustaining higher rates of DPT coverage than neighboring countries in central and southern Africa.13, 14 Unlike many LMICs, Malawi’s vaccine coverage is higher in rural compared to urban communities (77% and 70% respectively 13), which may be linked to HSAs’ unique ability to reach hard-to-reach populations with immunization services. HSAs have been attributed with increasing vaccine acceptance and uptake of the human papillomavirus (HPV) vaccine introduced in Malawi in 2019,15 and reaching Malawi’s prison populations with routine vaccines.16
Research Findings
HSAs and supervisors described important advantages to having HSAs administer vaccines, including their relationships with and accessibility to community members. Most respondents viewed HSAs as trusted vaccinators and service providers. In reference to community trust in HSAs, one HSA shared:
[If] another person goes there with the vaccine, people will not receive it but if it is an HSA, they say our doctor has arrived.
Several respondents commented that use of HSAs as vaccinators was key to Malawi’s success in reaching relatively high levels of immunization coverage. When asked, government, partner, and HSA stakeholders interviewed all agreed that other countries should follow Malawi’s example and use CHWs to administer vaccines, provided they can be sufficiently trained and supported. Relieving nurses of vaccination duties helps maintain a more manageable workload for nurses and other health workforce cadres.
Vaccine Administration
HSAs provide all standard EPI vaccines and were trained to administer COVID-19 vaccines. HSAs administer vaccines at both fixed sites such as hospitals or health centers and during outreach sessions in their communities. HSAs tend to conduct outreach sessions in teams of two to four, with responsibilities split up between team members. Outreach sessions occur at community locations including schools, churches, small shelters, and occasionally out in the open. HSAs described a clear understanding of their roles and responsibilities and reported vaccine administration as a core responsibility, though they also have many responsibilities outside of vaccination.
Table 2
Vaccination-related responsibilities | Responsibilities beyond vaccination |
● Submitting requisitions for vaccines and supplies ● Maintaining vaccine inventory and expiration records ● Compiling and submitting vaccine reports ● Planning and conducting vaccination sessions ● Informing community members about vaccination ● Reporting adverse events related to vaccination | Provision of routine preventive services ● Administering and counseling for medication and supplements such as ART, albendazole and vitamin A ● Conducting under-five clinics ● Participating in sexual and reproductive health programming, including educating pregnant women and administering family planning methods Health promotion ● Conducting infectious disease prevention activities such as for cholera and malaria ● Coordinating youth-friendly programs ● Conducting community education and social mobilization for various health initiatives ● Supervising and participating in water and sanitation programs Other health systems roles ● Conduct disease surveillance ● Support disaster preparedness |
Vaccine Demand Generation
HSAs are also tasked with RI demand generation activities such as giving health talks to community members (some reported using tools like flip charts and posters), mobilizing community members for RI, and answering questions about vaccines. Most HSAs report providing counseling to caregivers related to their children’s immunizations, such as explaining the immunization schedule, how vaccines work, expected side effects, the benefits of vaccination, and dispelling myths about vaccination.
When asked about RI challenges, many HSAs cited difficulties related to demand generation activities, such as talking to caregivers who have doubts about routine immunization for their children. More recently HSAs have faced significant issues encouraging the uptake of COVID-19 vaccines. Most HSAs named demand generation and vaccination activities as their most time consuming activity.
Vaccine Safety
To ensure potency of vaccines, HSAs are trained to routinely check vaccine vial monitors (VVM), monitor vaccine refrigerator temperatures, and use vaccine carriers or cold bags to maintain the cold chain when taking vaccines for outreach. HSAs are taught to always check the expiry dates and VVMs of their vaccines prior to administering them in facilities and prior to packing them up to take to the community. HSAs also play a central role in documenting and reporting adverse events following vaccination (AEFI). If an AEFI is identified, HSAs report them to the district using a standardized form and screen the patient for clinical follow-up care, if needed.
HSA supervisors enthusiastically agreed that maintaining vaccine safety was a significant part of their jobs, which they do through on-the-job coaching and direct observation while HSAs vaccinate. Supervisors ensure that HSAs are following vaccine safety best practices such as ensuring vaccine quality and potency, administering the vaccine correctly (correct syringe, correct amount, on the correct child), and discarding syringes and vaccine supplies safely.
HSA Training
Before they are allowed to administer vaccines, all HSAs are required to attend a standardized HSA training administered by the Ministry of Health (MOH) and lasting between 8–12 weeks (the duration has evolved over the years). The training content is based on MOH guidelines that outline HSA roles and responsibilities, and thus includes other topics such as family planning, TB and sanitation, but is heavily focused on immunization. HSAs estimated at least 50% of content was immunization-focused.
HSAs are assessed at baseline and endline, and given exams and practical exercises throughout the training. Whenever there is a new vaccine introduction or significant guideline change, HSAs said they participate in subsequent 1–2 day trainings or “briefings.” Table 3 lists training topics that were highlighted in key informant interviews.
Table 3
HSA Training Topics Related to Vaccination
● Pharmacology of how vaccines work ● How to conduct community vaccine education & outreach campaigns ● Vaccine storage best practices; concept of first expiry-first out (FEFO) ● Cold chain requirements by vaccine type ● Record keeping, including basic vaccine inventory management ● Vaccine administration methods (how and where on the body to inject) |
*Note this is not an exhaustive list of all training topics |
Most HSAs agreed that their initial training was adequate to get them started on the job, but felt additional on-the-job learning to hone their skills was also critically important. Supervisors agreed that the initial training is comprehensive in terms of the theory provided, but emphasized that close supervision and support is important for new HSAs to develop practical skills. HSAs also overwhelmingly expressed a desire for more refresher trainings to keep their knowledge updated and adequately answer questions from their communities. One HSA described forgetting key vaccine information:
Sometimes we find ourselves forgetting, for example how to vaccinate, how to store the vaccine, and how to know that this vaccine is damaged [or] expired. We need to always remember these things.
HSA Supervision
Interviewees consistently described HSA supervisors as playing a crucial role in supporting HSAs to administer vaccines. HSA supervisors regularly observe HSAs vaccinating in health facilities and while doing outreach in communities, where they provide tips and feedback to HSAs while they are on the job. Using a supervision checklist as a guide, they observe everything from how HSAs document their services provided and commodities used in reporting forms, to physical vaccine administration, to how HSAs interact with and answer questions from caregivers. Supervisors also take steps to provide quality control over the vaccination process by double checking vaccine expiry dates and VVMs before HSAs take vaccine supplies into the field, ensuring that the timing of the vaccine provision matches what is on the patient’s vaccination passport, and ensuring that the vaccine is injected in the right part of the patient’s body. Supervisors are also responsible for ensuring the availability of sufficient vaccine supplies for HSAs, collating HSA statistics on supplies and services provided, and facilitating relevant transportation for vaccine supplies and HSAs.
Table 4
HSA Supervisor Responsibilities Related to Vaccination
Supply Chain: ● Ensure availability of vaccines for HSAs (place vaccine supply orders and manage inventory) ● Organize transport for outreach visits ● Provide oversight to ensure vaccine fridges are working, make alternative plans in event of a power outage, ensure cold chain is maintained from static to outreach clinics ● Consolidate monthly reports from HSAs on services provided and commodities used Vaccine Safety: ● Observe HSAs vaccinating to make sure vaccines are administered correctly ● Provide oversight on vaccine quality and potency checks, including checking VVMs and expiry dates ● Ensure safety of HSAs while vaccinating (e.g., practicing injection safety, wearing masks, etc.) Admin/General Management: ● Provide performance feedback while observing HSAs ● Hold monthly review meetings at the health facility with HSAs ● Organize other supplies (e.g., uniforms, airtime, paper forms, boots, rain coats, backpacks, etc.) ● Prepare work plans for HSAs ● Maintain regular contact with HSAs and answer questions via phone/WhatsApp |
Logistics & Vaccine Supply Management
The vaccine supply chain in Malawi is parallel to that of other commodity groups, with separate transportation and reporting functions. Vaccine products are stored at the district warehouse, and distributed to health clinics on a monthly basis. The quantities distributed are based on a monthly report that consolidates inputs from HSAs on how many products were used and estimated needs for the following month based on each HSA’s target population. Figure 1 outlines the monthly downstream flow of vaccine products to HSAs, the transportation modes that are used, and the upstream flow of supply chain data from the community level to the district.
Although vaccine product stock outs were described as rare, there are some supply chain challenges, most commonly related to lack of reliable transportation. Vaccine supply orders can only be filled if there is fuel available at the district to deliver the supplies, otherwise HSAs must collect the order themselves or borrow from a neighboring health facility. HSAs frequently described placing emergency orders as a measure to avoid stock outs, indicating that the monthly ordering and reporting may not accurately predict true demand. Multiple HSAs commented that the unpredictable nature of how many people will show up to receive vaccinations at outreach sessions can also cause stock shortages.
HSAs and supervisors play an important role in maintaining the cold chain. HSAs regularly use cooler boxes and vaccine carrier bags to transport vaccines to and from community outreach sessions. Supervisors must ensure that the cold chain is maintained by monitoring fridge temperatures and electricity availability at the health facility, and verifying that HSAs transport vaccines appropriately. Approximately half of HSAs interviewed expressed a need for more vaccine carriers, especially to use during vaccine campaigns when HSAs are all deployed at once.
The MOH is responsible for providing transportation to deliver vaccines for HSAs to vaccinate in clinics and outreach sites, but HSAs and supervisors frequently mentioned major transportation challenges. Transportation issues and lack of fuel can delay vaccine distributions and limit the frequency of supportive supervision visits and review meetings. HSAs reported needing to travel long distances to pick up vaccine supplies and conduct outreach activities. HSAs might walk, use bicycles, motorcycles, government ambulances or other vehicles, or public transport when fuel is not available. One HSA said,
When we arrive, they will tell us they do not have fuel. But we have already told people that we will meet them at the clinic. We pay for the bicycle taxi, so we carry our vaccine, after arrival we administer the vaccine and then we carry back the remaining vaccine and return it. We use our money for expenses. We have used our money just because we want to save a Malawian child’s life.
HSA Professional Support
HSAs are salaried employees of the MOH, whose monthly payment is based on their professional grade and typically provided through banks in a reliable manner. Almost all interviewees felt the salary was too low, citing both the quantity of work HSAs do and inflation. Some reported receiving lunch allowances for community work, since it involves traveling to villages far from home, but immunization outreach was not included in this. Practices for reimbursement varied depending on the supporting partner, and HSAs described several unreliable methods and instances of never receiving promised reimbursement for participating in an activity. In addition, HSAs regularly have additional tasks added to their list of responsibilities without a corresponding increase in the workforce, consistent with what has been cited by several other studies on challenges faced by community health workforces.17 COVID-19 provided an extreme example of this, as it added significantly to HSAs’ workload without any task shifting of other responsibilities. Supervisors lamented the lack of fuel and motorbikes to conduct supervision visits, and others noted the need for more bicycles, as well as gumboots, umbrellas and raincoats for the rainy season.