When Dickson Nansima Mbewe was young he remembers the community health worker (CHW) who helped people in his village in the Mulanje districts in southern Malawi. “I was so interested to know what this health care worker does in our area.”
He saw her giving immunizations, visiting people’s homes and helping his community. He was very interested in her work, so in 2006 after he completed secondary school he wanted to become a health surveillance assistant (HSA) as CHWs are known in Malawi. Officially hired as an HSA that same year Dickson has been serving communities in Kasungu district in central Malawi now for over 17 years.
Dickson received 12 weeks of training before being assigned his own community, and he still feels privileged to be an HSA working for the Malawi Ministry of Health (MoH). HSAs in Malawi have been delivering health services, including immunization services, since the 1950s, but the job was not formalized in the health system with training, supervision and salary until 1998.
In 2015 Dickson was promoted to his current role as a senior HSA. He said that this role keeps him very busy as he is now responsible for supervising 50 HSAs and 100 community health volunteers while still serving a community of over 400 households. Dickson has opportunities for training and expanding his skills as an HSA, though not as many as he would like. In 2008, he was trained as an HIV testing and counseling service provider.
“Now I am the district supervisor for HIV testing and counseling services,” Dickson said. “I am enjoying this and being a senior HSA – getting to hold important positions within the ministry to serve my community.”
Dickson said there are many things he loves about his job because it is dynamic and he learns so much every day. He said the best part is getting to go into different communities and meet and talk with so many people. He enjoys meeting community leaders and religious leaders – and the general welcome he always receives from the community.
“Being an HSA in Malawi is like having a PhD – in the community they call you a doctor,” Dickson said. “They really appreciate the HSAs and they see the positive role we play. Whatever health issues come to the community the HSA is the first person to take care of them.”
Dickson does wish the government would extend the HSA training from 12 weeks to one year. “We are assigned a lot of duties,” he said. “Whatever comes – we are responsible for it. Most of the time we do on the job training – we learn by asking, we learn by seeing and we learning by doing. Sometimes we just do trial and error.”
Dickson said despite CHWs be a formal part of the Malawi health system they still have a lot of struggles. In addition to not getting enough training Dickson said their salary is very low, and many times HSAs have to work without supplies. They often do not have personal protective equipment (PPE) or even stationary for notes and data collection. They are also last in line for many health products.
He said sometimes he supervises HSAs that do not see the job as a calling. “When I meet these people, I firstly tell them to like their job, and second to like their community,” Dickson said. “Because all of this work that we do is to educate, help and serve our communities.”
Dickson said in 2020 he was chosen as a member of the COVID-19 resource team, whereby he had to go to hospitals and homes to care for those infected with COVID, as well as take away and bury those who died from the virus.
“We were not getting anything extra for this – but for me it was about serving my community,” Dickson said. “So, when someone says they do not like the job I first try to explain my story – I try to tell him/her the goodness of liking the job. Because if you like the jobjob, you will not feel discouraged.”
Even though Dickson loves his job, he would like to find the funding to get more formal education in community health. “Now as an HSA my knowledge is from experience, from trying this and that,” he said. “But if I can go to schoolschool, I will be able to serve my community even better.”
Dickson also helps to advocate for HSAs in Malawi by speaking with district leaders to share HSA challenges that are then passed on to the Malawi MoH. However, he said progress through government is very slow. He advocates for CHWs at the global level as well and is part of the CHW Speakers Bureau for the Community Health Impact Coalition.
One important message he has for all stakeholders working in global health is – do not forget about CHWs. He said governments must take the lead in ensuring CHWs are supervised, paid, supplied and integrated into the health system, but implementing partners and funders must help fill the gaps.
“Don’t forget to include us in your budgets and workplans.” Dickson said to partners and funders. “So many people depend on us to save their lives, we need to depend on you.”
Hear more from Dickson on our Products to People Podcast, Episode 2: Supplies Beyond the Health Facility. Listen now and subscribe to our podcast.