Leveraging community health workers as vaccinators: a case study exploring the role of Malawi's Health Surveillance Assistants in delivering routine immunization services.

BACKGROUND: Global chronic health worker shortages and stagnating routine immunization rates require new strategies to increase vaccination coverage and equity. As trained, trusted members of their local communities, community health workers (CHWs) are in a prime position to expand the immunization workforce and increase vaccination coverage in under-reached communities. Malawi is one of only a few countries that relies on CHWs-called Health Surveillance Assistants (HSAs) in Malawi-to administer routine immunizations, and as such offers a unique example of how this can be done. CASE PRESENTATION: We sought to describe the operational and programmatic characteristics of a functional CHW-led routine immunization program by conducting interviews with HSAs, HSA supervisors, ministry of health officials, and community members in Malawi. This case study 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. Interview participants consistently described HSAs as a high-functioning vaccination cadre, skilled and dedicated to increasing vaccine access for children. They also noted a need to strengthen some aspects of professional support for HSAs, particularly related to training, supervision, and supply chain processes. Interviewees agreed that other countries should consider following Malawi's example and use CHWs to administer vaccines, provided they can be sufficiently trained and supported. CONCLUSIONS: This account from Malawi provides an example of how a CHW-led vaccination program operates. 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. However, more research is needed to produce evidence on the impact of leveraging CHWs as vaccinators on patient safety, immunization coverage/vaccine equity, and cost-effectiveness as compared to use of other cadres for routine immunization.

Improving uptake of cervical cancer screening services for women living with HIV and attending chronic care services in rural Malawi.

Malawi has the second highest age-standardised incidence rate and the highest mortality rate of cervical cancer in the world. Though the prevalence of HIV is currently 11.7% for Malawian women of reproductive age, cervical cancer screening rates remain low. To address this issue, we integrated cervical cancer screening into a dual HIV and non-communicable disease clinic at a rural district hospital in Neno, Malawi. The project was implemented between January 2017 and March 2018 using the Plan-Do-Study-Act model of quality improvement (QI). At baseline (January to December 2016), only 13 women living with HIV were screened for cervical cancer. One year after implementation of the QI project, 73% (n=547) of women aged 25 to 49 years living with HIV enrolled in HIV care were screened for cervical cancer, with 85.3% of these receiving the screening test for the first time. The number of women living with HIV accessing cervical cancer services increased almost 10 times (from four per month to 39 per month, p<0.001). Key enablers in our QI process included: strong mentorship, regular provision of cervical cancer health talks throughout the hospital, nationally accredited cervical cancer prevention training for all providers, consistent community engagement, continuous monitoring and evaluation, and direct provision of resources to strengthen gaps in the public system. This practical experience integrating cervical cancer screening into routine HIV care may provide valuable lessons for scale-up in rural Malawi.