1. 1 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

2. 2 Global Experience of Community Health Workers for Delivery 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. 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. 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. 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. 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. 7 Lessons: Much is widely agreed, but key 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. 8 Next phase in strengthening also 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. 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