Credentialing CHWs in Support ofCompetency-Based Task Shifting
Dr. Jose M. Zuniga on behalf ofCHW QA and Credentialing Task Team
Task shifting to CHWs is not new
• CHWs are not a new addition to our health systems
• CHWs are associated with the Alma Ata primary care movement, but they long preceded this movement
• CHWs are also known as lay health advisors, promotoras, patient navigators, doulas, community health agents, etc.
What have we learned?
• Elements of ideal CHW program
– Emphasis on priority health needs of the population
– Adequate training, supplies, and supervision; and feasibility of technical competence needs of the population
– Improved accessibility, acceptability, and participation of beneficiaries
• Impact on health services delivery and benefits
– Selection of more efficacious interventions
– Improved quality of care
– Greater coverage and equity, and reduced disparities
Roots of credentialing
• Credential derives from the Latin credere, or “TO PUT TRUST IN”
What do we mean by credentialing?
“A standardized process whereby a skills-based metric is utilized to verify the ability of non-professional health workers to perform certain tasks previously performed by higher-level cadres of health workers, given proper training and supportive supervision.”
TO PUT TRUST IN…
Why are they important?
For the HRH agenda:
• Quality assurance
• Benchmarking
• Incentive
• Driving change
Benefits of CHW credentialing
• Advance legitimacy within health and human services communities
• Improve outcomes related to CHW services
• Help open the door for CHW reimbursement
• Offer assurances to current and potential CHW employers that credentialed CHWs have basic competencies
Potential problems with CHW credentialing
• Erosion of indigenous qualities that make CHWs effective (a critical asset for program success)
– Encourage priority credentialing of current CHWs
– Encourage CHW programs to supplement formal training with training specific to the community served
– Ensure CHW training builds upon CHWs’ affinity with their home communities
• Loss of current non-credentialed CHWs
– Create credentialing credits that currently practicing CHWs can obtain, such as on-the-job training, hours of service, and other life experiences that contribute to effective service delivery
• Other unforeseen problems
– Involve currently practicing CHWs in developing and refining a new credentialing program
CHW QA and Credentialing Task Team
• Co-Chairs
– Adele Webb, ANAC; and Jose M. Zuniga, IAPAC
• Advisors
– David Benton, ICN; and Fadwa Affara, ICN
– Charles Farthing, AAHIVM
– Greg Grevera, ANAC
– Eric Hefer, IAPAC; and Debra Shikati, IAPAC
Objective
To identify generic nomenclatures, competencies, and competency-based credentialing mechanisms as part of a response to assuring the quality of the contribution made by CHWs in support of scaling up access to HIV/AIDS services.
Phase 1
• Preparatory Phase
– Recommend generic nomenclature to identify categories of CHWs
– Recommend a generic list of competency-based tasks by category of CHW
Informed by GWU/SPHHS Regulatory Framework Group, Antwerp/PIH/Harvard Clinical Mapping Teams, WHO resources, IAPAC Clinical Competencies Survey, IMAI clinical care competencies matrices, etc.
Phase 2
• Development Phase
– Identify ways of crafting quality improvement and competency-based credentialing mechanisms by category of CHW
– Submit a draft report on quality improvement and credentialing of CHWs (allowing for country feedback)
– Submit a final suite of reports on quality improvement and credentialing of CHWs
– Present final report in October 2007
Strategically addressing resistance
• Congratulations to WHO and PEPFAR for recognizing the importance of professional associations and engaging with us as stakeholders to make this effort politically viable
• Not surprisingly, many professional associations have historically opposed and resisted the delegation of tasks to other cadres of workers
• Resistance to delegation is not exclusive to “elite doctors”
Times are changing…
• Preliminary results of reveal agreement around shifting 236 of 271 tasks from physicians to nurses
– e.g., prescribe first-line ART, prescribe simultaneous TB and ART (where appropriate), recognize/manage IRIS
• Preliminary results of survey reveal agreement around shifting 76 of 236 tasks from nurses to CHWs
– e.g., basic HIV education, pre-ART counseling, ART support, rapid HIV testing (and confirmatory HIV test)
• Key clause in question: “given adequate training, evaluation (credentialing), and supervision”