This transcript was automatically generated using software, with additional editing afterward, and may contain minor inaccuracies.
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Elie Hassenfeld: [00:00:00] Hey, it's Elie. It's the beginning of day three and we're just outside our hotel right on the side of Shire River in Liwonde in southern Malawi. Today we're first heading to a health outpost, which is run by a health worker. And we've been hearing a lot about these health workers who go out to rural areas and provide health counseling for things like family planning, for antenatal visits, for child health.

And, you know, we've heard from a lot of people that this is a big part of Malawi's health system. It's also been a part of the system that's been pulled back due to aid cuts. And so, we're gonna spend several hours there talking to the, hopefully, the provider, if they have time, but also patients about why they're coming to seek care and their access to care and, you know, see what we can learn.

Later today we're driving on to Lilongwe, Malawi's capital, where we're going to meet with the senior-most health bureaucrat in the government. And we're really excited to [00:01:00] get his perspective on, how he thought about the response that Malawi made to the aid cuts, what he thought about the cuts. We'll also ask him about the government support units that we supported in Malawi. And then just generally ask him about his perspective on Malawi's success in improving its health over the last 25 years. So that's our plan for today; excited to see what we learn.
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Elie Hassenfeld: In the morning we headed out to a health post. These are the furthest-out health facilities that serve people who live in very rural areas. We had to drive down long dirt roads and arrived at one pretty small brick building, probably 15 feet wide and maybe 50 feet long, consisting of two rooms. One which is a main room where, you know, people could be seen and then a second, smaller room, reserved for women coming to receive family planning counseling and services and also doubled as a supply room where [00:02:00] needed medicine and other health supplies were kept.

The first conversation that I had was with a disease control surveillance assistant. They're known as DCSAs, and they're healthcare workers who are really the frontline workers in Malawi's health system. Unlike many other countries where these health workers are volunteers or paid a small amount of money, in Malawi's system, they're full-time staff.

I talked to one of these DCSAs, and he told me that his major focus is on helping to care for children under five, making sure that parents know what treatment they can receive and ensuring that children receive the treatments. Here's some of what he shared.
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Elie Hassenfeld: How long have you worked as an HSA?

DCSA/HSA: Almost five years now.

Elie Hassenfeld: Five years now?

DCSA/HSA: Yes.

Elie Hassenfeld: What do you do on a normal day in your job?

DCSA/HSA: Mostly, I'm working disease control, to make [00:03:00] sure, people understand more about healthy more, especially prevention because our job is to reduce some cases. Maybe, community to know more about the prevention.

Elie Hassenfeld: And can I ask you a question? Do you come to this location normally?

DCSA/HSA: I have my own catchment area. Each of the HSA has their own catchment area.

Elie Hassenfeld: Do you know how many people or households are in that catchment area?

DCSA/HSA: Yes, in my catchment area I have 422 households and 1,274 people.

Elie Hassenfeld: On a daily basis, do you come to a specific point and then people come to you? Or do you go house to house?

DCSA/HSA: It's house to house. Because when people come to me, they don’t feel comfortable, so I don't know more about my people, but when I go house by house is when I know all. This [00:04:00] household, they're doing A, B, C, D. So each and every household has beliefs about health, that's why I love to go house by house.

Elie Hassenfeld: OK. I want to ask you something else, which is, you know, this year there was this stop work order, and I'm curious what effects you saw from the stop work order.

DCSA/HSA: Because of what happened early this year, it's difficult for us to work because people love to receive the services in the catchment area. So most of the activities is funded by donors. So dropping out of donors is challenge to us. Maybe people think like, yeah, family planning services are no longer available in other health facility.

Elie Hassenfeld: So were there services that had to stop because of the reduction in money?
DCSA/HSA: No, the service is still provided, but the issue of transports, logistics. [00:05:00] Transporting, especially as HSAs, they use motorbike to conduct the activity in the catchment area. Most especially in hard-to-reach areas. So . . .

Elie Hassenfeld: So you're saying that other HSAs would use motorbikes?

DCSA/HSA: Yes.

Elie Hassenfeld: But you don't have to use a motorbike?

DCSA/HSA: It depends the catchment area you came from. So no fuel provided to such kind of programs. So people are suffering because of distance.

Elie Hassenfeld: I see. So what happened is there were funding cuts. And then what you saw is less transportation available for HSAs. And so then that means where before HSAs could reach their whole catchment area, including harder-to-reach areas, now they can't reach as many people. Is that still stopped? Has anything changed recently or has that just stopped earlier this year and has stayed?

DCSA/HSA: No.

Elie Hassenfeld: It's back?

DCSA/HSA: It's back. From January, our partner that provides family planning services, they stopped. So the communities start worrying. Ah, where is our partner? [00:06:00] It was affecting us, but now it changes.

Elie Hassenfeld: Okay. Were there other effects from the cuts that you mentioned?

DCSA/HSA: It's the issue for transportation. Issue of capacity building.

Elie Hassenfeld: And so capacity building, that's training, training to do more things?

DCSA/HSA: Yes. For health workers, and community members. We have volunteers in community, local leaders. All of us who are supposed to go to training in specific activities. We are supposed to work hand-in-hand with the volunteers there in community, local leaders. So the cut brings a gap between the community and the HSA. So it's difficult to work without training.

Elie Hassenfeld: Got it. Have those trainings started again or that's stopped?

DCSA/HSA: No, I don't have any training since it stopped.
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Elie Hassenfeld: My next conversation was with a midwife. This is another health worker who [00:07:00] is out in rural areas, but her main focus was on pregnant mothers. In Malawi's health system they are really trying to target the leading causes of death, and that means that they're focused on pregnant mothers who themselves are at risk and their unborn children, and then children in the first five years of life. Here is some of what I learned about her work.
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Community midwife: I'm a community midwife. We work in communities helping mothers in reproductive health, issues of antenatal, family planning, postnatal. So we do clinics and outreach clinics. We have two health outposts.

Elie Hassenfeld: How many years have you been a CMA?

Community midwife: I have been a CMA for seven years now.

Elie Hassenfeld: Seven years. And so this year, America, it had that stop work order. And so what do you observe? What do you see? How has that, has that changed anything [00:08:00] for you?

Community midwife: Yeah, it's changed a lot because those clinics, I was saying babies antenatal, they are healthy because that has been there for so many years. Though people were working in the neighborhoods, but they were also conducting outreach clinics. So this time the clinics were affected too. And when I was coming in May, I found out that there were no clinics conducting during those days because of issues of transport and the other things.

Elie Hassenfeld: I see. So let me see if I understand. You work in these two clinics?

Community midwife: Yes.

Elie Hassenfeld: And they were also supposed to be outreach clinics for other health issues, like under-five, maybe children or something else?

Community midwife: Yes. Under five is also sometimes be conducted and it has been stopped due to issues of drugs and the other services were not there.

Elie Hassenfeld: Oh, so there weren't supplies of the drugs?

Community midwife: Yes. [00:09:00]

Elie Hassenfeld: And you observed that in the two clinics that you work in?

Community midwife: Yeah.

Elie Hassenfeld: How far away are those clinics from here?

Community midwife: The nearest is just minutes from here.

Elie Hassenfeld: Just minutes from here. I see. And the further one is an hour on motorbike?

Community midwife: Yeah.

Elie Hassenfeld: And you said you go there—on Monday you go to one, on Friday you go to one.

Community midwife: Yes.

Elie Hassenfeld: And then remind me, so the other three days, you're supposed to do the home visits, but you can't really do them?

Community midwife: We conduct them, but we can't conduct the whole.

Elie Hassenfeld: Because you can only go where you can travel?

Community midwife: Yes.

Elie Hassenfeld: And what do you do? Do you walk or something else?

Community midwife: Walk.

Elie Hassenfeld: Yeah. And so when people come to see you at the clinic, what do they come to see you for?

Community midwife: ANC, antenatal, family planning.

Elie Hassenfeld: So antenatal is women who are pregnant who are just coming for a check-in?

Community midwife: Yes.

Elie Hassenfeld: And what kinds of things do you check?

Community midwife: We do full physical examinations. We do some HIV testing. Conduct HIV testing is combined [00:10:00] with the hepatitis B and syphilis testing. We also give immunizations. We also give antimalarial drugs.

Elie Hassenfeld: And you do that for everyone who comes in?

Community midwife: Yes.

Elie Hassenfeld: Okay. So we were talking about changes that happened because there was the stop work order, and so does that mean that like do you go to clinics less often or HSAs have to go to clinics less often?

Community midwife: Yeah. So the people we are supposed now to go to for ANC. And including that we have those investigations, testing of HIV and others. We have other staffs who help us in conducting those tests. So they are from Baylor, so Baylor stopped the . . .

Elie Hassenfeld: That's a partner organization?

Translator: Baylor Malawi

Elie Hassenfeld: Like a Malawian NGO that was doing HIV testing?

Community midwife: Yes. So they also stopped working because of funding issues. [00:11:00] So when I go to the clinic, I alone can go, if I can afford, I can go to the clinic, but I don't have someone to test for those women. So they are supposed to go back to the health center for testing because we have only few HSAs who are trained in testing.

Elie Hassenfeld: So then they have to go to the health center.

Community midwife: Yeah.

Elie Hassenfeld: Okay. So before Baylor Malawi would come to the health post to help with testing, but then they had to stop work.

Community midwife: Yes.

Elie Hassenfeld: And then that stopped this year?

Community midwife: Yes.

Elie Hassenfeld: Did it start again?

Community midwife: They started in April, I think.

Elie Hassenfeld: Do you remember when it stopped?

Community midwife: It stopped in January.

Elie Hassenfeld: January. So it stopped in January and then they came back in April?

Community midwife: Yes.

Elie Hassenfeld: Did you see people coming in who asked to be tested?

Community midwife: People were coming, but there were no people who test them here. Because as we run the healthcare center, we have only two HSAs who are trained in HIV testing.

Elie Hassenfeld: Right. Can we just talk about family planning for a minute? So do you, [00:12:00] can you do family planning counseling?

Community midwife: Yes.

Elie Hassenfeld: And you can provide short- and long-term family planning?

Community midwife: Yeah, I do counseling. And I provide short-term methods and some long methods, like those implants. But I'm not trained in any IUCD and the others like permanent.

Elie Hassenfeld: How does the counseling go? Meaning, do you go to women and say, have you thought about family planning, do you want to talk about family planning? Or do people come to you and say, can you help me figure out how to do family planning?

Community midwife: Okay. There are two ways. When we are at the clinic, we tell the women all the methods that we provide, the importances, their side effects, and everything about them. So it's for them to make a choice, right? When they make a choice, [00:13:00] we do a one-on-one counseling in the method they have chosen and we provide the method.

Elie Hassenfeld: Yeah. What do you think are the biggest obstacles, or like problems, things that prevent women who want family planning from accessing it? Some people don't want it, but if they don't know what it does or it's just difficult to access?

Community midwife: Right now we can't say that it's difficult to access because we are having so many NGOs coming in with the family [00:16:00] planning issues in our communities. So, but the issue always stays on culture and the traditional beliefs. Yeah, some are deeply rooted in traditions and beliefs, even if you can counsel them more and more. Some are resistant to change.

Elie Hassenfeld: And traditional beliefs is like you shouldn't use family planning?

Community midwife: There are some who believe that family planning is something that affects men [00:14:00] in families. Some, they feel if you are not yet started childbearing and you are having family planning methods, then you'll be barren. Some feel like if you take more family planning methods, then you'll be barren forever. So there are some issues that prevent them. But all in all, people are by and by understanding the issues.​
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Elie Hassenfeld: And then finally, I spoke with a doctor who was the person in charge of a larger health facility, roughly 15 minutes away by car. So it was the closest larger health facility to this health post that we had been visiting. Here's some of what we discussed.
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Elie Hassenfeld: What were the effects that you observed from the cuts?

Doctor: After the cuts?

Elie Hassenfeld: Yeah, like how did things change if they, if they did?

Doctor: A lot has been changed, starting from the issue to do [00:15:00] with trainings. So each and every staff were offered some trainings, just about capacity building. So since the stop order, currently we haven't undergone any kind of trainings.

Elie Hassenfeld: So can you tell me a little bit about the trainings? It sounds like, just regularly you're training HSAs to do new things.

Doctor: So for any kind of changes that happens, any new guidelines, the HSAs are supposed to undergo the trainings. So since the stop order, the HSAs are just working without even having some updates, some trainings, yeah. If there is a change in the treatment guidelines, they have to undergo the training. So they haven't . . .

Elie Hassenfeld: How often would the trainings happen before the cuts?

Doctor: Mostly, at least every quarter they need to have a training. Every quarter. Every, if it's about a month, so we, we call it review meetings.

Elie Hassenfeld: So because of the cuts, you haven't been able to do trainings?

Doctor: Not yet. Not yet.

Elie Hassenfeld: And why did the cuts reduce [00:16:00] the trainings?

Doctor: A lot of trainings were funded by the USAID NGOs. So those trainings were also facilitated by the USAID NGOs.

Elie Hassenfeld: NGOs, like what? Do you know which NGOs?

Doctor: All the WHO programs. Okay. Starting from the Save the Children. Our main partners, Baylor, Baylor Medicine. Yes, a lot of them, Emmanuel International.

Elie Hassenfeld: Then what are other things that have been affected? You said, because you said a lot changed. So one is training.

Doctor: Yes. The other issues are to do with the supplies, starting from the drug supplies. A lot of malarial commodities were offered by the USAID. So we can say the goodness, but during the malaria season is when we experienced high consumption of the antimalarials. Okay? So the stop order happened after the rainy season. That was the goodness. But if it was done during the rainy season, it would've faced a lot of challenges.

Elie Hassenfeld: I see. So it was probably [00:17:00] fortunate that it happened this time of year. What else, like supplies, were missing or low?

Doctor: When it comes to HIV, it's commodities also. Currently we have a certain regimen of drug that we only have a few in stock. And also, this transportation itself. If we have an emergency order, we have at our facility we experienced the stockouts. At the district, they have enough stock. So the stock to come here at the facility, we need, we really need the transportation. The USAID team for Baylor used to do the transportation system. Okay? So after the stop order, we struggled a lot for us to do the emergency order. Because we are only depending on the government to send the ambulances to deliver the drugs.
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Elie Hassenfeld: So we're just sitting here inside, in our hotel in Lilongwe, the capital of Malawi. [00:18:00] Today we spent most of our day at a health outpost. And these health outposts are a really critical part of Malawi's health system because they're fairly rudimentary structures that offer services to women seeking family planning and caregivers bringing their young children in need of diagnosis and medicine for things like malaria, pneumonia, or diarrhea.

So we're glad to see it because it just gave us a better sense of how the Malawian health system works. We didn't get a ton of new insight into the effect of aid cuts, and really today was mostly informative by just giving us better insight into this important component of the health system.

So, Julie, I know that when we were there you talked to a bunch of women who were there seeking family planning services. Just tell us a little bit about what you heard.

Julie Faller: So I spoke with a few people who were there seeking family planning services, and the first person that I spoke with, I thought it was really interesting hearing the flow of her [00:19:00] experience as a patient seeking family planning services.

I was trying to ask whether she had gotten full information about the range of options before she chose her option, which was a long-lasting implant. And she said, yeah, that after she gave birth to her baby in the health center, which is like one level up from the health post where we were, that the nurse had counseled her about different options. And she went home and thought about it and decided that the long-lasting one was the right one for her. And then when she was ready, she came back to the health post instead of going back to the center so that she didn't have to travel as far to actually get the implant.
So I thought that was just an interesting example of people interacting with different levels of the health system and choosing the one that was most convenient for them.

Elie Hassenfeld: Right, because one major idea of the way that Malawi's set up its health system is, we just heard this so many times, like trying to put services out close to communities as much as possible. And that's like the health outpost, meaning the building that's stocked with supplies and the health workers who are trained and who are out there and are often going door to door. And that accessibility [00:20:00] is a really major part of what they're trying to do.

Julie Faller: Yeah, it's definitely what they're trying to do. And then I think another patient that I spoke with also showed, they've made a ton of progress and there's still a ways to go. And so this woman said that she had started walking to get to the clinic at eight in the morning and I think arrived around ten in the morning. So she walked quite a ways to get to the post, not clinic, the post.

And she was excited to be there. She was gonna switch her method from injectables that require a nurse to inject to Sayana Press. And what she was most excited about was that Sayana Press lets you do the injections yourself. And so instead of having to come back every three months and do this, I guess, four-hour round-trip walk, she could come back every nine months and just handle it herself at home.

Elie Hassenfeld: Yeah. And then I also had a chance to talk to the health worker that provided some family planning counseling to people. And one of the questions I asked her was, what do you think is the biggest obstacle to people accessing family planning?

Is it supplies, meaning like the right methods aren't in stock when people want them? Is it information? [00:21:00] Like do people know what they do? And she said it's really neither of those. She thinks people have information and normally the commodities are available. And instead she said it was misinformation.
And in particular, she said one of the most common pieces of misinformation she experiences is people who have what she called "traditional beliefs," which is that taking contraception could have some negative long-term effect. And so the example she gave was that a woman who takes family planning or uses family planning before having a child will be barren for the rest of her life.

And we asked her—because you know, often people are seeking her out for counseling—why would someone seek her out for counseling if they had that belief? What are they doing? What she said was that often people are sort of, I don't know, ambivalent or uncertain, and they see some benefits, but they also have this belief. And they talked it through with her.

I asked her if she thought she was changing people's minds or convincing them, and she said, mostly no. Like you know, once people have beliefs, they have beliefs, there's not much you can do. That seemed like the challenge that she was pointing to. [00:22:00]

Did you also talk to other folks in the health facility about what they were dealing with?

Julie Faller: Another person that was on my mind was actually, I think possibly the same midwife assistant that you talked with. I spoke with her later, and I was asking just about her practice, and she was saying, in addition to family planning counseling, she provides antenatal care and referrals.

And it came up in the, I was asking what sort of services she gives, and in that context she was mentioning that during the freeze, as we already heard, HIV testing was suspended during that time, which we knew. But what was interesting is she said that it had a negative effect on people coming to seek out her care in the communities.

Because when HIV testing was happening in the communities, they'd go and they'd get tested and then she'd counsel them. And that was sort of done, but without the testing, they would come to her and she'd say, okay, go to the health center. And they're sort of like, so why did I come to you anyway? And she thought that that caused people to basically see no point to the community-based care. And [she] was saying now they're starting to learn that it's coming back [00:23:00] up, but that it'll take time to build back up that knowledge.

Elie Hassenfeld: Right. And one other person that I spoke with was a health worker who had participated in a malaria net distribution a couple years ago. And he just talked me through the process, which was interesting to hear what it is and how he sees it. First, they go through 10 days of registration where they have to reach every single household in the area that they're responsible for. He was responsible for a little bit more than 400 households.

He also said a similar thing about misinformation. The kinds of questions he gets are people will say, oh, I've heard about these nets. I don't want them because we know that if you sleep under a net you can't conceive a child. And then he has to talk to them, and that was just part of his job, was trying to talk that through with people.

So overall this day was interesting because this community-based healthcare is integral to Malawi's health system. It's something that, you know, we've looked at a lot across different organizations, across different countries, and, just being there, talking to people who are responsible for this day to day is [00:24:00] really helpful.