A new Mental Health in Zomba Project seeks to strengthen the system of community mental health care and improve mental health care throughout Malawi by developing the enhanced role of Health Surveillance Assistants (HSAs).

Jerome York-ZombaUK partners from the Tees and Wear Valleys NHS Foundation Trust have been working in the Zomba district of Malawi for almost fifteen years, as part of the Zomba Mental Health Link, registered with THET.  The Health Partnership has worked closely with Malawian colleagues on five key areas of education and practice development:

  • Occupational therapy and rehabilitation services
  • Community and epilepsy services
  • Children’s services
  • Care of people with HIV/AIDS and other physical illness
  • Supporting leadership and management structures and processes

The partnership has also informed governance and government policy, creating a sustainable future for long-term mental health care in Malawi. This new Mental Health in Zomba Project seeks to strengthen the system of community mental health care by developing the enhanced role of Health Surveillance Assistants (HSAs).

HSAs are village based health workers who have a unique insight into the local community and will be able to recognise and respond appropriately to those experiencing mental health problems.

A previous pilot study showed that HSAs in Malawi are ideally placed and willing to respond to the mental health needs at community level, but this requires appropriate training, on-going supervisory support and organisational backing.

As such, the project seeks to develop the capacity of HSAs to implement front-line mental health care, scaling this up to a district-wide level, which serves a population of 550,000. The project also seeks to demonstrate the health system changes required for successfully integrating such mental health care provision into primary health care.

The project will be implemented by two passionate partners: The Department of Health Sciences at the University of York in the UK, and Zomba Mental Health Services in Zomba, southern Malawi.

Reacting to the news of the grant, Jerome Wright, project leader from the University of York, said:

‘It’s really exciting to get this grant because it will allow us to put into place what we’ve been planning for many years. We’ve looked at how we can integrate mental health care into primary care in the most cost effective and supportive way that is culturally attuned to the Malawian community.’

People with mental health problems in the local community will benefit from the increased training of HSAs and the services they can offer. HSAs will be able to detect those with mental health problems earlier, assess and refer those at risk of harm to self and others, and implement psychosocial rehabilitation for those with mental health problems.

Jerome Wright recalls the positive impact of training Health Surveillance Assistants in a recent pilot study:

‘There were people who had major problems with epilepsy, and to be able to have some medication on a regular basis made a huge difference to many people’s lives. One person, who had fallen into a fire whilst fitting, has now received regular treatment to stop fitting and has had very few fits since, and is now looking after family and doing fine.’

The Zomba Mental Health Link was attuned to creating a sustainable approach to mental health care and sustaining the benefit of projects long after funding has ceased. The Mental Health in Zomba Project is no different.  The project is designed to demonstrate how mental health might be implemented in a community context and within general health care provision.

The Malawian Ministry of Health has already recommended that local District Implementation Plans devote funds to community mental health and is keen to see an effective and low-cost community-based mental health provision that reduces the ‘treatment gap’. If the district-wide scale-up is successful, it is feasible that the Project could be rolled out nationally in all districts of Malawi as part of each District Implementation Plan, and that the HSA mental health care syllabus could be incorporated into the national curriculum for all HSAs.

On the question of sustainability, Jerome Wright comments:

‘We’re hoping our work will contribute to a national health worker system. If that happens, the possibility of it scaling up to other districts outside of Zomba is increased. The Ministry of Health is keen on that but, as always, it’s important that we work out the effectiveness, feasibility and the impact of such a change for the Health Service Assistants, the community, and the mental health services.’


The Republic of Malawi is a landlocked country in the southeast of Africa, with a population of almost 15 million (14,901,00). It is one of the poorest countries in the world, with a short life expectancy of 44 years for men and 51 years for women. The under-five mortality rate is high, with 92 deaths out of a thousand live male births and 119 for female births. (WHO 2008)

Malawi has a particularly high prevalence of HIV among the population, with 110 adults per thousand suffering from the condition; this is compared to a regional average of 47 per thousand.  There is a chronic shortage of health workers (0.02 doctors and 0.60) nurses per thousand people. Total expenditure on health is 6.6% of GDP but only 1.5% of the Malawian public health budget is spent on mental health. (WHO 2008)

Malawi has very limited specialist mental health care services, with only 1.5% of public health budget spent on mental health and most of this supports the one state psychiatric hospital at Zomba (Government of Malawi 2011).  The Malawian Government is committed to the decentralisation of mental health services and its integration within primary care.

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