The Future of the CHW– Lessons from HIV Programs

1. 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 African Platform on HRH

2. Global Experience of Community Health Workers forDelivery of Health Related Millennium Development Goals: A Systematic Review, Country Case studies, and Recommendations 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 of vaccines 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

3. 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

4. GHWA Consultation (Montreux) • Integrate Community Health Workers (CHWs) fully into national 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 regular and continuous supportive supervision, health and safety issues, CHW's information and communication needs, a clean environment, a manageable workload, and the availability of drugs / supplies /equipment.

5. 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

6. 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 –

7. 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?

8. 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?

9. 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 make to better health care and reaching health targets