Community Care Workers – Addressing the Health System Crisis

1. Community Care Workers Symposium“Exploring Alternatives”29th, 30th April and 1st May 2010The utilisation of Community Care Workersin an age demanding extraordinary responses to health care-Dr Jack Lewis, CMT -Dedicated to Andrew Warlick

2. Community Care Workers – Addressing the Health System Crisis • The Challenge: • The Human Resource Crisis in Health • The Increasing demand on our Health System • The Solution: • Task Shifting / Task Sharing • Community Care Workers

3. Where are we? Key Health Status Indicators 458 951 people were estimated to be receiving ART in December 2007. This figure jumped to 700 500 by December 2008. Just over half (53%) of those needing ART were accessing it – in both the public and private sector.

4. The Challenge: The Human Resource Crisis in Health • Roughly 66% of South African doctors and 50% of the nation’s nurses are employed in the private sector. • As of 2005 only 14% of people in South Africa were covered by the private sector. • The Private sector consumes roughly 60% of all health expenditure. • 29.9 % of public sector health posts were vacant in 2006. • The ratio of professional nurses per 100,000 public sector clients has declinedfrom 120.3 in 2000 to 109.5 in 2006. • This translates to approximately 1.1 professional nurses per 1000 population • WHO’s recent target of 2.28 professionals per 1000 population for the countries taken as a whole

5. The Challenge: The Increasing Demand on our Health System • The number of patient visits to Primary Health Care (PHC) facilities has increased by 52% in seven years: from 67,021, 961 patient visits in 1998/1999 to 101,758,377 in 2005/2006. • Utilisation rates have increased from a national average of 1.8 visits per person per year in 1998/1999 to 2.2 visits per service user per year in 2005. • Where the average is 2.2 health facility visits per service user per year, a person on ART makes an estimated 7.62 visits to health facilities annually, 364% over the national average. • If an additional 750 000 people are initiated by 2011-12 as required by the 80% access target of the NSP that means at least 4 million additional hospital visits annually. Statistics South Africa, 2005; HST, 2000 & 2006; DoH, 2007

6. The Challenge: How is our understaffed health system going to cope with this simultaneous shortage in supply and scale-up in demand?

7. The Solution: Task Shifting/Task Sharing The idea of Task Sharing is common to all major documents concerned with health service delivery: • National Strategic Plan for HIV & AIDS and STI 2007-2011 (NSP). • National TB Strategic Plan 2007- 2011 • Report of the Ministerial Task Team on Health Workforce report May 2009 • SANAC TTT on Treatment Care and Support report on Task Shifting July 2008 • SANAC TTT on Treatment Care and Support Task Shifting recommendation May 2009

8. The Solution: Task Shifting/Task Sharing • This crisis of limited supply and increasing demand in health, has led to the WHO and other global organizations to call for an introduction of task-shifting or as it is called in SA Task Sharing, into the care and maintenance of those with HIV/AIDS. • The WHO defines “task shifting” as “a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers”. (WHO: /HSS/2007/03). The 2008 recommendations include inter alia: • Countries should consider implementing and/or extending and strengthening a task shifting approach where access to HIV services, and to other health services, is constrained by health workforce shortages. Task shifting should be implemented alongside other efforts to increase the numbers of skilled health workers. • Countries deciding to adopt the task shifting approach should define a nationally endorsed framework that can ensure harmonization and provide stability for the HIV services that are provided throughout the public and non-state sectors. Countries should also explore a framework for the exploration of task shifting to meet other critical public health needs.

9. The Solution: Task Shifting/Task Sharing • Community care workers, including people living with HIV/AIDS, can safely and effectively provide specific HIV services, both in a health facility and in the communityin the context of service delivery according to the task shifting approach. • People living with HIV/AIDS can be empowered to take responsibility for certain aspects of their own care. People living with HIV/AIDS can also provide specific services that make a distinct contribution to the care and support of others, particularly in relation to self-care and to overcoming stigma and discrimination.

10. The solution: Community Care Workers (CCWs) Given the extreme resource constraints of South Africa as a developing country, usage needs to be made of semi-skilled health workers as an intermediary and support to the core health system. Within this context the strategy of using Community Health Workers represents one of the most efficient interventions to integrate communities with the health service (and related social services and social grants). - The Workforce Force Requirements For The South African Health System, Report of the Minister’s Advisory Committee on Health, Workforce Technical Task Team, May 2009 The Technical Task Team (TTT) on Treatment, Care & Support is of the view that CCWs represent a major opportunity for achieving significant improvements in health outcomes in a cost-effective manner. Training for such less-specialized workers is cheaper and more rapidly accomplished due to their more constricted skill set, making them an attractive new cadre for health facilities (Callaghan and Schneider, 2007: 3).

11. The Solution: Community Care Workers (CCWs) The NSP recognises the following roles for CCWs in health service delivery and that without CCWs fulfilling the following roles “achieving the targets and objectives of the NSP” will be impossible: • High quality counselling for purposes of HIV counselling and testing (including finger and heel pricking) • Post-exposure prophylaxis (PEP) and psychological support for survivors of sexual assaults, • Prevention of mother-to-child transmission (PMTCT) and follow-up care for HIV positive women after pregnancy, • Psychological support, • ART adherence (and we would add side effect) counselling and treatment literacy in the community, • Support for children (and we would add care givers of children) living with HIV, • A comprehensive package of palliative care to children and adults.

12. The Solution: Community Care Workers (CCWs) National TB Strategic Plan (TB SP) “envisages trained lay people assisting with the clerical workload of TB control programme to relieve the nurses to do clinical work i.e. data clerks. & TB assistants” Functions of the CCW according to this plan include: • Verifying address of all new patients and educate patients and their families on the plan of treatment. • Ensuring regularity of DOT and administer DOT five times a week throughout the treatment period. • Ensuring that follow-up smear examinations of sputum are carried out as per the stipulated schedule. • Maintaining the Treatment Card information & ensuring that the Patient Card is given to the health care worker for entry in the Clinic/Hospital Card and TB Register. • Assist with contact tracing - Taking steps for immediate retrieval of defaulters. It should be no later than the day after the default. (we would add loss to follow up) We would argue that all of these functions would equally apply to CCWs employed in the HIV/AIDS programme and most other chronic illnessess.

13. The Solution: Community Care Workers (CCWs) 20 Outcomes for health Service Delivery 2010-2014 : Dr. Aaron Motsoaledi, Minister of Health Budget Speech 13 April 2010 – 1.Increased life expectancy at birth (HIV / TB related / CCW) 2.Reduced child mortality (HIV/ safe feeding / TB Related/ CCW) 3. Decreased maternal mortality (HIV related/ CCW) 4. Managing HIV prevalence and improving the quality of life of PLW HIV AIDS (CCW) 5. Reduction of new HIV infections (CCWs) 6. Expanding access to the PMTCT programme (CCW) 7. Improved TB case finding (CCW) 8. Improved TB treatment outcomes (CCW) 9. Improved access to antiretroviral treatment for HIV-TB co-infected patients (CCW) 10. Decreased prevalence of drug resistant TB (CCW) 11.Revitalisation of primary health care (CCW) 12. Improved physical infrastructure for healthcare delivery 13. Improved patient care and satisfaction (CCW)

14. The Solution: Community Care Workers (CCWs) 14. Accreditation of health facilities for quality 15. Enhanced operational management of health facilities 16. Improved access to human resources for health 17. Improved health care financing 18. Strengthened health information systems (HIS), including strengthening information, communication and technology (ICT) 19. Improved health services for the Youth 20. Expanded access to home based care and community health workers. Health Seeking Behaviour “The main objectives of the campaign are to encourage South Africans to know their HIV status; to equip those who test HIV-negative with ways of ensuring that they do not get HIV; to increase health-seeking behaviour; and to create a quick and easy entry point to accessing wellness and treatment services for those who test HIV-positive.” Dr. Motsoaledi

15. Community Care Workers (CCWs): Key Issues • Our experience in CMT suggests that properly trained CCWs are able to perform a broad public health function. They provide the bridge between the client and the health system, ensuring that users of the public health system both access protocols as intended and are able to incorporate them into their culturally mediated personal routines. • CCWs can provide public health education and support around a range of chronic and infectious diseases which, if treated early and effectively would keep large numbers of people out of hospital, with their families and in employment. The social impact of this is huge and would more than offset the cost of providing the service. Areas where CCWs could be active include: • HIV/AIDS • TB • STIs • Hypertension • Obesity • Diabetes • Epilepsy

16. Community Care Workers (CCWs): Conceptualising this Human Resource What is needed to achieve this is consensus on the professionalizing of the role of CCWs and a common understanding of their: • Role and function • Training • Remuneration and employment • Management (including M&E)

17. thank you