The Role of CHWs in multidisciplinary care teams and the XIX International AIDS Conference

By: Joan Holloway

Currently more than seven million HIV-positive people are eligible for antiretroviral treatment globally but are not receiving it. Health system challenges, including the shortage of a well-trained health care workforce have created barriers to scaling up HIV care and treatment. Recognizing the critical shortage of health care workers in low-and middle-income countries, the International Association of Physicians in AIDS Care (IAPAC) has, for several years, explored ways to engage with health professionals and other health care workers to improve the quality and efficiency of HIV care delivery and increase access to treatment, care and support services.

Evidence in the literature shows that efficiencies can be achieved and patient outcomes and satisfaction improved when health care workers provide care in multidisciplinary care teams (MCT).

With support from the U.S. National Institutes of Health (NIH), IAPAC conducted two consultations on a MCT approach. The first consultation in Washington, DC in December 2010 focused on identifying MCT characteristics. The second, in Addis Ababa, Ethiopia, in December 2011, identified successful African MCT models and studied their current practice – what the teams look like, how they function, and their training needs. Representatives from six African countries, the WHO, CDC, PEPFAR, academic institutions and donors attended. (A report of the consultation is available here on CHW Central.)

The meeting defined multidisciplinary care as: a partnership between health care workers of different disciplines and cadres, inside and outside the health sector and community, working together to provide comprehensive, efficient and continuous health services.

Five models utilizing CHWs were presented: TASO Uganda, FHI eastern and southern Africa-specific models, Partners in Health Rwanda, a health extension worker model in Ethiopia, and NUMAT, a post-conflict model in Northern Uganda. From these models we learned:

Services provided by teams of health care workers should be accountable to and governed by the local community
A supportive regulatory and policy environment is necessary to support the health workers
Practice is moving faster than regulatory changes; health regulatory authorities can become partners in identifying solutions to workforce shortages
Consensus regarding the critical role of CHWs in providing HIV/AIDS services and in linking the team to the community was achieved
CHWs have different names, roles and responsibilities, and length and type of training in each of the models—many are paid workers, some are volunteers
Task-shifting to CHWs expanded as a response to the HRH crisis and the burden of HIV/AIDS and CHWs became the interface between the formal health system and the community
Community-based programs and the use of CHWs have been most successful in countries where CHWs are a recognized cadre of health care workers, salaried and formally integrated into the health system.

Following the consultations, IAPAC was awarded funding to implement Year 1 of a three-year MCT initiative in several African countries in order to investigate the effectiveness and efficiency of MCT models in addressing integrated HIV service delivery and HRH challenges. Ethiopia was selected because of its leadership in HRH and its integration of health extension workers into the government health care system. The Ethiopian Ministry of Health, the HIV/AIDS Prevention and Control Office (HAPCO) and Jimma University have all agreed to partner with IAPAC. IAPAC and Jimma will start the baseline assessment of two health centers in Ethiopia in August. A MCT approach will be introduced into one of the health centers; the second will serve as a control site.

Since there is so little documented in the literature about this approach, we would very much welcome your thoughts and experiences with multidisciplinary care teams in HIV/AIDS health care delivery sites to help us to strengthen and focus our model.

Questions:

What is your experience with multidisciplinary care teams?
In your experience is there an equitable allocation of tasks among health workers or are too many tasks being shifted down to the CHWs?
Are the CHWs paid? If so, do they receive a salary or a stipend?
Are CHWs recognized by the government regulatory authorities or professional councils as a cadre of workers?
Are you aware of patient/provider satisfaction studies of CHW-delivered HIV/AIDS services? If so, what were the findings?

Joan Holloway is the Vice President for Global Health Initiatives at IAPAC, an organization representing over 17,000 HIV/AIDS providers globally, where she is responsible for global health workforce initiatives. She joined IAPAC from the Office of the U.S. Global AIDS Coordinator, where she was the Senior Technical Advisor, Human Resources for Health and Health Systems Strengthening, and Country Liaison Officer for Vietnam. A health care administrator and former U.S. Public Health Service Commissioned Officer, Joan previously served as the Department of Health and Human Services’ (HHS) Director of the Division of Training and Technical Assistance in the HIV/AIDS Bureau. Joan has managed both community-based and hospital-based primary care facilities. She was the first director of the Division of Programs for Special Populations in HHS’s Bureau of Primary Health Care where she was responsible for the administration of, among other programs, the Health Care for the Homeless Program and community-based HIV/AIDS programs. Joan has Bachelors and Masters degrees from Hunter College, a certificate in health records administration from the U.S. Public Health Service and a certificate in health systems management from Harvard University. She is the recipient of the Distinguished Service Medal, the U.S. Public Health Service’s highest award, for her work with underserved and vulnerable populations.