As low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the potential for community health workers (CHWs) to take on a growing role in strengthening health systems. Health surveillance assistants (HSAs) — as the CHW cadre in Malawi is known — play a vital role by connecting the community with the formal health care sector. Yet, little is known about the routine experience and challenges faced by HSAs, as their roles and responsibilities have grown due to task shifting. A situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba District, Malawi was conducted, focussing on HSAs’ perspectives collected through focus groups and interviews. The findings show that HSAs face numerous challenges related to training, as well as challenges in defining their roles and those of their supervisors, and setting priority tasks by HSAs, their supervisors and policy makers. The paper concludes with recommendations to improve HSA training and policy, with the ultimate goal of improving the effectiveness of this cadre of worker, and improving the health of the population.