Review of evidence and some policy options

1. Review of evidence and some policy options Helen Schneider

2. 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).

3. 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

4. Outline • Current situation in SA: desk review and 2 districts • Policy proposals for re-organisation of roles – DOH & DSD • International evidence • Questions

5. 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!

6. NPOs in two sub-districts Khayelitsha (n=56) BBR (n=47)

7. CCWs in the two districts Khayelitsha BBR • Population +/- 500,000 • 1124 CCWs • 1 per 444 people • Extrapolate to uninsured national: 84,000 • Population +/- 600,000 • 1311 CCWs • 1 per 457 people

8. 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.

9. 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).

10. 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

11. Distribution of CCWs Khayelitsha (n=1124) BBR (n=1311)

12. Current roles (cont.) • Uncoordinated, inefficient, inequitable, poor referral • Relationship with formal health system and providers poor

13. 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

14. 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”

15. 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

16. 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

17. 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

18. 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)

19. 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

20. 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

21. Expected working hours Khayelitsha BBR

22. 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?

23. 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

24. 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

25. Option 1: one pool • 575 workers

26. Option 2: segmented pool