Institutt for sosialantropologi

A Foot in Each Camp: Health Surveillance Assistants as mediators in the social interface of child health in Malawi


By Mette Ommundsen

Supervisor: Associate Professor Frode Storaas


Malawi is a poverty struck nation placed in-between Tanzania, Mozambique and Zambia. The professional health care sector is struggling to meet the needs of its population with only two physicians per 100.000 populations. Educating medical doctors is expensive and many doctors and nurses leave the country in order to work in places more profitable, like the UK. Most doctors who do work in Malawi stay in the cities; yet 80 % of the Malawian population live in rural areas. In order to provide health care in rural areas, Health Surveillance Assistants have been established. HSAs are recruited from rural communities and are given seven weeks pre-service training, ideally, and are supposed to perform preventive health care in rural areas. They conduct under5 static and outreach clinics where they weigh and vaccinate children, in addition to performing other preventive health initiatives. HSAs are government engaged ‘locals’.

This thesis reveals some weaknesses regarding HSAs medical skills which might have negative effect on the vaccination service they perform. However, the thesis also focuses on their strengths as health care providers, which I argue is the closeness, geographically and socially, to the community they are working within. Because of this closeness, people trust they have good intention and bring their children to child health activities. Trust in medical workers is not a given. In many societies vicious rumours concerning health workers and global health incentives are present which make people refuse to engage with medical offers. In this community rumours concerning the nurse and the medical assistant arose, and tension existed. HSAs, because of their in-between position in the community, meadiated tension directed towards the health centre. By cycling into various villages with vaccine equipment and preventive health advice, HSAs are bridging the health centre to the community. The thesis explores the dialectic between HSAs’ weaknesses and strengths and concludes that HSAs are very important in bringing health care to the rural population, despite their medical weaknesses.