Leveraging Community Health Workers as Vaccinators: A Case Study Exploring the Role of Malawi's Health Surveillance Assistants in Delivering Routine Immunization Services

"Leveraging CHWs as vaccinators is a promising yet under-explored task-shifting approach that shows potential to help countries maximize their health workforce, increase vaccination coverage and reach more zero-dose children."

In many countries, community health workers (CHWs) play a key role in demand generation for primary health services, including routine immunisation (RI). As trained, trusted members of their local communities, CHWs are in a position to expand the immunisation workforce and increase vaccination coverage in under-reached communities. However, CHWs are rarely enlisted to administer vaccines. Malawi is one of only a few countries that relies on Health Surveillance Assistants (HSAs), who are CHWs, to administer vaccines. This paper describes the operational and programmatic characteristics of a functional CHW-led RI programme, drawing on 36 interviews conducted in March 2022 with HSAs, HSA supervisors, ministry of health officials, and community members in Malawi.

In providing context, the paper explains that HSAs are full-time CHWs and receive salaries on the government payroll. HSAs are responsible for administering an estimated 80% of routine vaccinations in Malawi, along with COVID-19 vaccines. Malawi consistently sustains higher rates of diphtheria, tetanus, and pertussis (DPT) vaccine coverage than neighbouring countries. Vaccine coverage is higher in rural compared to urban communities (77% and 70%, respectively), which may be linked to HSAs' ability to reach hard-to-reach populations with immunisation services. HSAs have been attributed with increasing vaccine acceptance and uptake of the human papillomavirus (HPV) vaccine introduced in Malawi in 2019 and with reaching Malawi's prison populations with routine vaccines.

This case study from VillageReach describes how and where HSAs provide vaccinations, their vaccination-related responsibilities, training and supervision processes, vaccine safety considerations, and the community-level vaccine supply chain. In general, Malawi's HSA programme was found to be consistent with the World Health Organization (WHO)'s vision for a professionalised community health workforce. Interview participants consistently described HSAs as a high-functioning vaccination cadre, skilled and dedicated to increasing vaccine access for children. They strongly emphasised that the primary advantages to having HSAs administer vaccines are their relationships with and accessibility to community members. Most respondents viewed HSAs as trusted vaccinators and service providers, and research indicates trust is a key factor in encouraging health behaviour change, such as vaccine uptake. When questioned about their perceptions of having HSAs administer vaccines, caregivers of children under five shared no hesitation or disagreement, indicating that this service delivery model is not negatively impacting demand or uptake of services.

One of the HSAs' tasks is RI demand generation activities, such as giving health talks to community members (some reported using tools, such as flip charts and posters), mobilising community members for RI, and answering questions about vaccines. Most HSAs report providing counseling to caregivers related to their children's immunisations, such as explaining the immunisation schedule, how vaccines work, expected side effects, and the benefits of vaccination, as well as 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 RI 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.

The primary challenge of using HSAs as vaccinators described is the risk of inadequate training and the potential for poor-quality work if not properly motivated and supported. Most HSAs and supervisors described their salary as insufficient given their growing workload and inflation, and HSAs frequently described using their personal resources for public transportation. Trainings, while thorough, are infrequent, and there are no routinely planned refresher trainings for HSAs; they are only conducted on an ad hoc basis when partners can provide funding, which results in many HSAs going for years with no training.

Thus, VillageReach urges other countries considering expanding the scope of CHWs in vaccine administration to pay close attention to the supportive infrastructure that enables HSAs to vaccinate effectively in Malawi. Specific recommendations include:

• Budget for transport and supplies.
• Conduct extensive foundational and routine training, in person or virtually, to help CHWs maintain their confidence and competence with vaccine administration information and skills.
• Coach and mentor CHWs using dedicated supervisors, who should be supported with adequate transportation resources to be able to conduct supervision visits.
• Provide CHWs with fair pay.
• Ensure a reasonable workload for CHWs.
• Consider "task-shifting" or "task-sharing" approaches in leveraging CHWs to administer vaccines.

In conclusion: "This account from Malawi showcases that national CHW cadres can successfully be trained, supported and consistently supplied with...products to provide routine immunization. This case study can inform other countries who may be interested in adopting this task-shifting approach....However, more research is needed to produce evidence on the impact of leveraging CHWs as vaccinators on patient safety, immunization coverage and equity, and cost-effectiveness as compared to use of other cadres for routine immunization."

Click here for a 5-page summary brief by VillageReach in PDF format.