Fifty-seven participants from six districts were included in the qualitative data set for this study, including in-depth interviews with 28 supervising and senior managers and four focus groups with 5–9 HSAs per group (). Managers interviewed for the study represented a range of positions within the district health management team and frontline supervisors, from district health officers to medical assistants serving as health center in-charges. All HSAs included in the study had received CCM training and were operating CCM clinics in the communities where they were posted and were representative of HSAs in the district. The following sections describe the themes that emerged from analysis of informants' perceptions about the CCM program, and contrast the perspectives held by program managers and HSAs ( and , respectively). The themes included community and health facility benefits of CCM; qualified endorsement of CCM by program managers; diverging perspectives on HSAs' roles as village doctors; and motivating factors for HSAs. No systematic differences in perceptions were found between high-performing and low-performing districts.
Description of respondents in the study, Malawi*
Managers perceptions about the CCM program, Malawi*
Motivating and demotivating factors associated with CCM work, as reported by HSAs, Malawi*
Community benefits of CCM.
Managers and HSAs agreed that the CCM program is helpful to the communities that it serves. The most commonly cited benefit for communities was increased geographic access to health services for children, discussed in 3 of 4 HSA focus groups and in 17 of the 29 manager interviews. As described earlier, the HSAs selected for CCM training were those stationed in areas designated as hard-to-reach, generally defined as being located ≥ 7 km from a health center. Informants reported that having a CCM clinic improved health care access for these communities:
“I like [the] village clinic because the community receives drugs near, and children, when they are sick, are treated quickly. So I like it because the community is not suffering.” (HSA) “I know that [HSAs operating CCM clinics] are coming from remote areas where medical treatment is a problem and I have supported the idea of giving them the drugs so that they can help the people in those areas” (medical assistant).
In addition to geographic access, managers believed that communities benefited from CCM because HSAs living in the communities were available to provide health services at all times (24 hours). Two managers stated that they expected that increased access to health counseling and curative services in the community through CCM would result in reduced use of traditional healers by community members. Informants also cited improved health outcomes and/or mortality reduction as a key benefit of the CCM program in 11 interviews and all focus groups. The HSAs believed that CCM benefited the community by creating more opportunities for community members to have contact with HSAs and receive health counseling.
Health facility benefits of CCM.
Aside from benefits to the community, managers reported that CCM had (or would have) benefits for health facilities, including reduced caseloads, improved work hours for medical assistants, and reduced operating costs for health facilities as a result of less use. Some managers noted a visible reduction in cases at the health center with the introduction of CCM:
“When I was coming [to this health center] three years ago, there wasn't this program and I was having much workload. Most of the patients who were coming were under-fives. After introducing this program, the workload has been reduced and you can find that children who come here are those from within the health center [vicinity] and not people from far places” (medical assistant).
Similar to managers, HSAs also believed that CCM reduced facility caseloads and eased the strain on facility-based clinicians. One HSA suggested that by reducing the number of facility cases, the CCM program has led to improved treatment of patients by medical assistants at the health facility, who were previously harsh to patients when busy.
Qualified endorsement of CCM by managers.
Although all managers included in this study made positive comments about the concept of the CCM program, these positive comments did not always indicate whole-hearted endorsement of the program. Several managers expressed concerns about CCM that qualified their positive assessment of the program. The most commonly stated concern was that HSAs needed support to provide a high quality of care, an idea discussed by 15 managers. The type of support that managers considered critical was primarily supervision, but also included drugs, equipment, and shelters for holding CCM clinics. The following comment from an IMCI coordinator reflects the common concern that HSAs must be supported.
“The quality of care that HSAs can provide will also depend on supervision or support that you are providing to them. These are not medically oriented personnel. We are making them to be medically oriented hence we need to provide them with the necessary support that they might require” (IMCI coordinator).
Similar comments made by other managers also tended to emphasize the low level of education or lack of clinical background among HSAs.
In addition to asserting the need for the CCM program to support HSAs, 11 informants qualified their support of the program by emphasizing the limited scope of CCM. The limitations described by informants included that CCM only addressed minor illnesses and specific conditions, and that HSAs were only allowed to treat children within a certain age range. The comment by one area environmental health officer that “[HSAs] are given a limit and they are performing within that range, which is good,” illustrates the beliefs of several managers that the CCM program should be circumscribed by clear boundaries.
The third manner in which informants qualified their positive assessment of CCM was by reserving their final judgment of the program, especially with regards to the question of whether HSAs are providing a high quality of care. Five respondents indicated that they felt it was too early for them to judge the impact or quality of the CCM program, or that they wished to see data to make a judgment.
Village doctors or stopgap measures?
During focus group discussions, HSAs strongly indicated that their new role of operating village health clinics changed how they view their own position in the health system. HSAs explained that, with CCM, the community recognized them as village doctors, and that they viewed themselves as being on more equal footing with Medical Assistants, the primary clinicians at Malawi's health centers. One HSA described the CCM training as having provided him with a new career, indicating a sense of significant change in his role, and a higher status within the health system and the community.
“In the past people [in the villages] used to call us doctors, but with this program, we are real doctors because [we are] giving them medicines and I feel happy that I am a doctor” (HSA).
Although HSAs expressed satisfaction at the prospect of a more important role in the health system and community, they were frustrated that this perceived change had not been more formally recognized by the health system. A common complaint voiced by HSAs was that their workload and responsibilities had increased but they had not received an increase in salary or incentives. Caregivers could bring sick children to the HSA at any time, and HSAs would have liked to receive allowances for working during the night and on weekends. Some HSAs also expressed a desire for non-monetary recognition of their perceived new role, such as inclusion in meetings with clinicians and new uniforms.
“We expected that after being trained, since we are now part of the curative part, there will be change in our monthly salaries but there is no change. Also we thought we will be given uniforms for our identification that these people are part of the health center of sub medical assistants (laughter from the group), but no change” (HSA).
The HSAs also expressed a wish to go further with the village clinics by treating more illnesses and different age groups, including older children and elders. For some HSAs, these wishes stemmed from a desire to be useful to the community, and other HSAs expressed an interest in receiving more training and skills that they hoped would lead to promotion.
Managers were aware that community members perceived HSAs as doctors, sometimes making little distinction between an HSA and a clinician at a health center. However, managers tended to regard HSAs as non-clinical workers with limited qualifications. Several managers described HSAs as not medically oriented, not clinicians, and not health workers. The manager's view of HSAs as non-clinical workers did not seem to have changed fundamentally with the addition of CCM to the HSAs' responsibilities. When asked his opinion about the CCM training course, one district environmental health officer said, “It is not complicated as if we are making them become doctors.” As mentioned previously, managers emphasized the limited scope of the CCM program, and some expressed a worry that with CCM, HSAs would become too confident and try to go beyond what the CCM program allows them to treat.
It may appear contradictory that most managers supported the provision of some curative services by HSAs despite believing that HSAs are not clinical providers. This seeming contradiction may be explained by the comments of several managers who justified the CCM program as a stopgap measure that addressed the human resource constraints in Malawi's health system. One IMCI coordinator said, “HSAs are not clinical providers, they are being used to provide CCM because of the problems we have at hand.” A district health officer described CCM as a good initiative but a less-than-ideal use of low-level health workers.
“This program is there because we want to deal with the crisis that we have in terms of human resources. If we had for example enough nurses who are purely trained community nurses, they could [be the] responsible people to run these clinics and not HSAs . . . To me I think the best way is to make sure that human resources are available and they should be [the] right human resources. I think the community health nurses are the lowest that we can try and do” (district health officer).
This district health officer supported the CCM program, given the deficit of human resources in Malawi's health system, but he would have preferred to have community health nurses provide community-level curative services. Other less frequent justifications that managers cited for HSAs providing clinical services were: 1) that the government has an ethical obligation to provide community-based services such as CCM, which was described by one DEHO as being “a program which deserves to be supported, because it addresses the poorest of the poor . . . so it's a human rights intervention;” and, 2) that HSAs were providing medications that community members could have purchased themselves in local shops.
Although many managers did not regard HSAs as clinical workers, most manager-level informants expressed a belief that most HSAs are meeting performance expectations for CCM. Most managers also made positive comments about the CCM training course, and a few indicated that they believed that HSAs might have been providing better care than patients would otherwise receive at the health center. These managers were impressed by the amount of time HSAs spent with each patient, and their thoroughness. A pharmacy technician assessed CCM quality as follows.
“There is quality of care [at CCM clinics] because they [HSAs] do not see many patients . . . they have time to examine the patient unlike at a district hospital where there is a long queue” (pharmacy technician).
Many managers also expressed a desire to see the CCM program grow. Eleven managers stated that more HSAs should be trained to provide CCM, and two managers believed that HSAs should treat patients of older ages, and one administrator believed that HSAs should provide a broader range of clinical services.
Motivating and demotivating factors for HSAs.
Comments made by HSAs during focus group discussions indicate that CCM work provides unique motivational factors beyond those that HSAs find in their traditional prevention work (). The HSAs expressed satisfaction at learning new skills and being useful to the community. In particular, HSAs reported receiving more appreciation from the community as a result of their CCM work.
“I am always happy when I hear from the caregiver that the child is now OK since I gave the child medicine. And [I] am so popular in that village because I am treating under-five children who have uncomplicated illnesses; those that are serious we refer and they come [to the health center] to get treatment. When the child is healed we are praised because we wrote a referral letter for them” (HSA).
Other HSAs described their pride at helping others, including their friends in the community, and their belief that they were contributing to the social and economic development of the country by operating village health clinics. Finally, the opportunity to receive allowances during training and review meetings was cited as a motivating factor by HSAs.
The HSAs also experienced new frustrations and burdens associated with their village clinic work. By far the most frequently mentioned demotivating factor for the HSAs was the perception that they were given a large responsibility without receiving the support needed to help them meet expectations. The specific issues involved in this type of complaint were many and varied; for example, different HSAs believed that they needed shelters for holding village clinics, materials for infection prevention, and more feedback and corrections from supervisors. Several HSAs described their frustration as resulting from broken “promises” and/or neglect by CCM program managers.
“We are human beings and we need to be corrected or appreciated on what we are doing because this helps us to change or know that we are doing better. As of now we are just working but we don't know whether we are doing better or not because they don't come to supervise” (HSA).
Several HSAs complained that supervisors do not respond to their complaints, and that despite making supervisors aware of their needs, their needs went unaddressed.
The second most frequent challenge reported by HSAs operating village health clinics was a conflict between CCM policies and community expectations. The HSAs reported that they received pressure from community members to treat children more than five years of age and even adults. The HSAs worried about the damage that may occur to their relationship with the community by refusing to treat patients that are outside of the CCM age limits. One focus group participant said that if an HSA turns people away, “they think you are a tough person and as a result people hate you.” Insufficient supplies, especially drugs, were also said to strain the HSAs' reputation with the community. Several HSAs expressed a desire for program managers to provide them with more assistance in communicating CCM policies to the community and in managing community expectations.
Additional burdens of CCM reported by HSAs related to time, finances, and safety risks. Most HSAs reported that the CCM program had increased their workload. During CCM training, HSAs were advised to select specific days during the week for holding village clinics. However, HSAs report that due to pressure from patients, they are not able to restrict the days and times when they do village clinic work. Having to attend to patients late at night and on the weekend was one of the most common complaints from HSAs. However, managers cited 24-hour access to care as a benefit and expectation of the CCM program. The HSAs also complained about the time burdens associated with completing multiple patient records and traveling long distances to the health centers to restock drugs. Aside from time burdens, HSAs reported paying out-of-pocket for transport to collect drugs and lamp oil and candles to see patients at night. Considering personal safety, some HSAs reported fears that they may contract infections from patients, or that attackers may try to steal their drug supplies.
Reports of resistance.
Although the informants in this study all indicated positive responses to CCM, managers from three districts and HSAs from two districts did report incidents of resistance to the program. Each reported incident involved medical assistants at the health center, who either refused to support the program or to provide drugs to HSAs. Some HSAs also accused medical assistants of being selfish by withholding adequate supplies of drugs even when they had sufficient stock to fully supply HSAs. Most managers who reported medical assistants' resistance to the program attributed this behavior to insufficient orientation of medical assistants at the start of the program or to staff turnover. Only one manager, a district environmental health officer, stated that medical assistants felt threatened by CCM, which could be considered an erosion of their influence. In all reported cases, the resistance was overcome by the district managers' efforts to convince skeptical medical assistants to support the program. These interventions included an informational meeting for all medical assistants in one district and individual contacts with resisting medical assistants in two districts.