REVIEW OF EVIDENCE AND SOME POLICY OPTIONS

Helen Schneider

Presidential mandate

From national accreditation to provincial “readiness assessment”

Decentralisation of ART/HIV care to PHC, integration with TB and maternal child health programmes

Implement task shifting/sharing recommendations, including nurse-initiated ART and lay counsellor HIV testing

Simplify clinical monitoring of patients Implement standardised M&E systems, including a

patient register Mobilise communities to test for HIV Counselling

and Testing (HCT).

Process

DDG Task team Good practices review:

‘Tried and tested’ report. Case studies of implementation

CCW component Desk review Data from 2 (sub)-districts Costing

Outline

Current situation in SA: desk review and 2 districts

Policy proposals for re-organisation of roles – DOH & DSD

International evidence Questions

Current situation

Large and rapid increase in CCW numbers over last decade: 5,600 (1997) to 65,000 (2009)

Employed through non-profit organisations 1,636 in contracts with 9 provincial health

departments (181 per province, 30 per district)

Under-estimate!

NPOs in two sub-districts

Khayelitsha (n=56) BBR (n=47)

CCWs in the two districts

Population +/- 500,000 1124 CCWs 1 per 444 people

Extrapolate to uninsured national: 84,000

Population +/- 600,000

1311 CCWs 1 per 457 people

Khayelitsha BBR

Current roles Oriented mainly to HIV and TB

some chronic, mental health, abuse, elderly, ECD

Facility based roles: Providing HIV counselling and testing services in antenatal, TB,

child health and general services Running educational activities Providing treatment preparation, counselling and education to

people attending ART and TB services Acting as case managers of HIV and TB patients (including basic

TB screening, completion of registers, identifying and arranging community follow-up of patients)

Acting as expert patients, facilitators and patient advocates.

Current roles (cont.)

Home based care roles: Arranging and providing treatment support or DOTS for

people taking ART, TB treatment and, in some instances, treatment for chronic non-communicable diseases, and trace those lost to follow-up

Providing home care and nursing to bedridden and ‘dehospitalised’ patients

Providing education, information and material support (e.g. food parcels)

Identifying and providing social support to orphaned and vulnerable children

Assessing and identifying household needs, acting as advocates and facilitating access to other services (e.g. grants).

Current roles (cont.)

Community based: Run support groups, income generating activities and food

gardens Care and support activities to orphaned and vulnerable children,

“drop in” centres Provide care and support activities to other vulnerable groups

(elderly, rape survivors etc.) Conduct community peer education, prevention and mobilisation Provide residential care (hospice) or places of safety for

vulnerable groups

Transitions in roles: Palliative care to chronic disease adherence Home to facility and community based Care to prevention

Distribution of CCWs

Khayelitsha (n=1124) BBR (n=1311)

Current roles (cont.)

Uncoordinated, inefficient, inequitable, poor referral

Relationship with formal health system and providers poor

CCWs: Terms in Khayelitsha

Abanalekeli Care aids Carer CDC facilitators Child Care Worker Coach Community Care workers Community carers Community Health Advocate Community Health Care

Workers Community Health workers Community workers Counsellor Educators Facilitators

Field worker Hlanganani Facilitator and

Recruiter Home based carers Home carers Lay counsellors Mentors Peace workers PTC Student Volunteers Trainers Treatment Literacy and

Prevention Practitioners Volunteer Youth Worker

Policy proposals

CHW policy framework 2004 Generalist CHW but did not preclude specialist

workers Community Care Worker Management

Policy Framework (V6) One single unified cadre for health and social

development “respond comprehensively to community

needs on community terms”

Policy proposals (cont.)

CCWMPF roles: Standard minimum skill set: health facility,

home and community + additional “applied” skills sets (possibility of teams)

Health: MCWH, mental health, TB, HIV&AIDS/STIs, non-communicable diseases, communicable diseases, nutrition

Social development roles: OVC, household support, child care forums, community care centres

87 separate items listed

Policy proposals (cont.)

MCWH: framework for accelerating Community-Based Maternal, Neonatal, Child and Women’s Health:

specific/focused activities based on evidence and targeted at pregnant women and their young children

International evidence Child Health:

Also maternal depression, mother-infant relationships

TB: Retention in care and adherence to TB treatment But not “DOT”

Chronic, non-communicable diseases: Minority populations USA Part of multi-disciplinary teams Improved knowledge, retention, lifestyle changes, outcomes Educator, case manager, role model, program facilitator and

advocate; within teams

International evidence (cont.) HIV:

Programmes rely heavily on lay workers HIV counselling and testing:

Increase access and perform safely Case/programme managers within facilities

Patient education, symptom screening, follow-up Community support promoting retention in care

and outcomes Community follow-up (Jinja trial)

International evidence (cont.)

Combining roles: “there has been a long and unresolved debate about the

question how many functions one CHW can effectively perform.”

“community health workers will probably perform better with clearly defined roles and a limited series of specific tasks than if they are expected to undertake a wide range of tasks or have an ill-defined role.”

Combining HIV with other roles: Limited evidence: HSAs in Malawi; HEWs in Ethiopia Generalists but with focused roles: not more than 10-15

built up over time Employed as part of teams Usually in the presence of other mid-level workers

International evidence (cont.) Importance of combining preventive,

promotive with “instrumental” roles Volunteer based programmes:

work for two hours or less a week No fixed expectation of labour

Expected working hours

Khayelitsha BBR

Questions

Roles What are priority roles? Teams or single worker? How far integration without losing effectiveness? Coordinating social development and health roles? What training? What preparation of other professionals? How to move from where we are now?

Questions (cont.)

Is the CCW category trying to combine too many functions and levels?

Mid-level worker roles Fulltime community worker with predetermined roles Community volunteer responding to community

identified needs and with no expectation of regular labour

Khayelitsha

575/1124 said did TB/HIV Employed (supervision) all at R1,100

costs R14,2m Integrated TB/HIV/HCT service in 2008/9

required: 69 facility based counsellors 170 treatment supporters (FTE)

If employed facility based workers at G2 (same as ENA) + 170 treatment supporters R3,500/month

Costs R14.9m Currently DOH +12m, +9m devoted to HIV

Option 1: one pool

575 workers

Option 2: segmented pool