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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 - PowerPoint PPT Presentation
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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
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