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African Platform on HRH
The Future of the CHW–Lessons from HIV Programs
International AIDS Society Pre-conference
Bridging the Divide:
Interdisciplinary Partnerships for HIV and Health Systems
July 16-17 2010, Vienna, Austria
Eric Buch
eric.buch@up.ac.za
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Global Experience of Community Health Workers forDelivery of Health Related Millennium Development Goals:A Systematic Review, Country Case studies, andRecommendations for Scaling Up Bhutta Z, et al (GHWA)
Dearth of evidence from good studies
Factors limiting the range, quality of CHW impacts
–Shortage of basic drugs and irregular supply ofvaccines and commodities (e.g. condoms)
–Inadequate and irregular supervision
–Lack of equipment and non-functional equipment
–Insufficient initial and continuing education
–Low status and remuneration of CHWs
–Inadequate linkages with health system
Recommendations
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CHW Program Functionality Assessment Tool
Good checklist – Used for GHWA case studies
•Recruitment
•The CHW Role
•Initial Training
•On-going Training
•Equipment and Supplies
•Supervision
•Performance Evaluation
•Incentives
•Community Involvement
•Referral System
•Professional Advancement
•Documentation, Information Management
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GHWA Consultation (Montreux)
•Integrate Community Health Workers (CHWs) fully intonational HRH plans and national health system
•Ensure a regular and sustainable remuneration stipend
•In scale up make provision for training, supervision,equipment and supplies, transport.
•Ensure a positive practice environment, including regularand continuous supportive supervision, health and safetyissues, CHW's information and communication needs,a clean environment, a manageable workload, andthe availability of drugs / supplies /equipment.
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Some of the lessons from HIV Programs
•Revitalized CHWs and emphasized key role
•Dedication
•Expert patients
•M&E importance and complexities
•Proper program management
•Need for effective organizations and support esp CBOs
•Questions about
–Scope of practice
–Workload – what is a fair workload
–Support systems
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CHWs as a layer of Health Workforce
•CHWs are part of, not in themselves the solution
•Balance between professionals, MLWs, CHWs (Mix)
–Task shifting
•Volunteer HWs
•CHWs (distinguished from Volunteers)
•Expanded role for Mid level workers
•Scale up professional training, enable retention
–Review curricula, incentive and practice environments
•Develop management and leadership
–
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Lessons: Much is widely agreed, butkey policy choices for the future
•Move away from single/double disease CHWs?
•Dedicated AIDS workers or chronic care or generalists?
•How wide can generalists scope be with competence?
•CHW teams: Chronic, MCH, Enviro, Rehab?
or generalists like Ethiopian HEWs (are they MLWs)?
•Paid or unpaid?
•How much treatment?
•Regulated and by whom?
•National competence based training, regulation?
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Next phase in strengtheningalso needs:
–Reduced walk to work ratios (>range of services)
–Clarity on workload and what is a visit
–Ensuring supervision and referral
–Working logistics
•What communication and transport
–Full not costing and funding?
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Most important lesson for next phase
•Re-emergence of CHWs comes with risks
•More than just topping up AHW
–AHW face major problems in spite of funding injection
•Make sure we do it properly
•If not delivering second class care for the poor,instead of the critical contribution CHWs can maketo better health care and reaching health targets