Community health nurse-midwives (CHNMs) have long been the backbone of primary healthcare in Malawi. But their dwindling numbers over the past two decades have quietly weakened service delivery, leaving thousands without consistent and nearby professional nursing and midwifery care.
Interviews with stakeholders and analysis of available data show that many rural communities increasingly feel abandoned as nurse-midwives disappear from the frontline of community healthcare, often redeployed to fill staffing gaps in already understaffed public health facilities.
vaccinates a baby
As their presence declines, health surveillance assistants (HSAs) are being forced to shoulder heavier responsibilities—often beyond their training—and frequently with limited supervision.
CHNMs play a vital role in promoting and protecting the health of individuals, families and communities. Their work includes community-based care, treatment and support, health education and disease prevention.
However, public health data indicates that Malawi has faced a chronic shortage of nurse-midwives for more than two decades, with the crisis becoming particularly acute in the early 2000s.
Paramount Chief Kawinga of Machinga says the shortage is already affecting rural communities.
“The shortage of community nurses has become a big challenge. Previously, they played a pivotal role in primary healthcare by managing chronic conditions and bringing nursing and midwifery services closer to villagers,” he said in an interview on Wednesday.
He noted that communities now receive fewer home visits, limited follow-up care and delayed referrals, steadily weakening the country’s primary healthcare system.
“Everyday we are losing people because community nurses are no longer readily available as the primary point of contact for timely healthcare. Their role in bridging the gap between villagers and the formal health system has been eroded and government needs to reflect on this,” he said.
Because of the shortage, many rural residents are forced to travel long distances to access healthcare services that previously would have been available closer to home through outreach activities.
Ministry of Health spokesperson Adrian Chikumbe confirmed that the country faces a critical shortage of CHNMs, most of whom are currently stationed at district facilities rather than within communities.
He said Malawi currently has only 344 CHNMs serving a population of about 19 million people—equivalent to roughly one nurse-midwife for more than 55 000 people.
This figure is far above the recommended ratio of one nurse-midwife for every 5 000 people.
“It is clear that the health system has gaps in responding to community health needs, forcing many people to travel long distances to access services,” Chikumbe said.
He added that although there has been no policy shift away from community-based care, the limited number of CHNMs has forced the health system to concentrate them at district level.
“The lessons learned over the years have underscored the need to deploy enough community nurse-midwives directly within communities so they can provide services at the lowest level of care,” he said.
Data from a public health research group shows the country also faces a shortage of about 7 000 community health workers. As a result, HSAs are increasingly overloaded with tasks such as community-based surveillance, vaccination campaigns and some elements of curative care.
While rural healthcare relies on both nurse-midwives and HSAs, these shortages have created major gaps in service delivery, with high workloads and structural challenges affecting performance.
The consequences are particularly severe in maternal health. Many women in rural areas still give birth without skilled attendance, contributing to high maternal mortality rates estimated at 439 deaths per 100 000 live births.
Some districts face especially severe shortages. Ntchisi, for instance, has only three community nurse-midwives serving a population of about 387 000 people, while Phalombe has four CHNMs serving more than half a million residents.
To address the crisis, the Ministry of Health has introduced a direct-entry community health nursing-midwifery technician programme aimed at increasing the number of professionals deployed at community level.
The syllabus and curriculum have already been approved by the Nurses and Midwives Council of Malawi, and training colleges are expected to begin recruiting students this year. Graduates will be deployed directly to communities.
Meanwhile, some responsibilities previously handled by community nurses are now being carried out by community midwife assistants (CMAs) and HSAs.
However, Malawi Environmental Health Association president Bertha Sato warns that such task shifting often blurs professional responsibilities and risks overburdening HSAs.
“It leads to HSAs taking up too many roles, reducing their focus on key responsibilities such as environmental and public health, including sanitation, hygiene promotion and community health education,” she said.
The country currently has about 17 800 HSAs serving communities nationwide, but supervision and mentorship remain inadequate, especially during disease outbreaks such as cholera, polio and mpox.
“When outbreaks occur, HSAs are expected to respond immediately as frontline workers, sometimes with minimal supervision or mentorship,” Sato explained.
According to government guidelines, one HSA is typically assigned to serve about 1 000 people, often covering large areas on foot.
Public health advocate Grace Ngulube believes the shortage of community nurses reflects a broader human resource crisis in the health sector and threatens progress toward global health targets.
With only a few years remaining to meet the Sustainable Development Goal of ensuring healthy lives and promoting wellbeing for all, she says the situation is worrying.
“When communities lack essential frontline services, it raises serious concerns about equitable access to primary healthcare. Rural communities lose consistent professional support for preventive care, maternal and child health monitoring and timely referrals,” she said.
Retired community nurse-midwife Rhoda Kamwamba also expressed concern, recalling how community nurses previously conducted regular home visits to identify illnesses early and support vulnerable families.
“Without routine home visits, illnesses often go unnoticed and pregnant women, newborns and other vulnerable patients miss critical early health checks.
“These nurses play a crucial role in identifying danger signs and ensuring people receive timely care,” she said.
