[pre-print] 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.

In this research, we 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.