The Partners In Health (PIH) model of partnering with community health workers (CHWs) in tuberculosis (TB) programs evolved out of our early experiences in the Central Plateau of Haiti. In the 1980’s, PIH co-founders Paul Farmer and Ophelia Dahl recognized that their first efforts to provide care for tuberculosis-infected patients were frustrated by low adherence to medication regimens, high loss to follow-up, and unacceptable levels of mortality. A root cause analysis conducted with clinicians and community health workers led to the realization that substandard clinical outcomes are not mere byproducts of the patients’ culture and poor personal decisions; instead, there are structural elements that can be addressed by modifying the systems serving the poorest, and therefore most vulnerable, patients. Step one was then — and continues to be — caring enough about the destitute sick to seek out and invest in such new approaches.
And so the concept of accompaniment was born: instead of blaming patients for their bad clinical outcomes, the clinical team would extend care logistically and philosophically to patients. The health care delivery value chain would later be used to understand and negotiate the sequence of events and inputs necessary to actually deliver and measure high-value clinical and programmatic outcomes.
PIH leaders describe how the concepts of accompaniment and quality care delivery across the value chain continue to invigorate the PIH model of including community health workers in TB programs.
Ralph Ternier, MD, MHSM, Zanmi Lasante, PIH’s sister organization in Haiti: “Accompagnateurs have been a core part of our care delivery team in Haiti for decades. They go to where the patients live and help them get better. It is so much more than just DOTS – they are the bridge between where the patient is emotionally and physically and the clinical services we are offering. The accompagnateurs’ successes in walking hand-in-hand with the patients inspire all of our other work.”
Oscar Ramirez, Ing., Socios En Salud (SES), PIH’s sister organization in Peru:
“We were one of the first groups to treat MDR-TB patients, and one of the first to get high cure rates (90% in our first cohort was cured). Now that these efforts have been transferred to the Ministry of Health and a more complex patient population is being treated on a much larger scale, the percentage is still quite high (around 70%). SES continues working closely with the MOH to find yet new ways to cure as many patients as possible. While we are very proud of this, we feel that none of this would have been possible without our CHWs that provide accompaniment and treatment support. The treatment for MDR-TB is difficult. It is long and fraught with side effects that would be unacceptable to anyone. The CHWs who work with SES provide the very real human touch that makes completing that treatment bearable.”
Sara Selig, MD, Associate Director, COPE, PIH’s sister organization in the Navajo Nation: “The health system in the Navajo Nation has seen the value in community health for years– they have had Community Health Representatives (CHRs) working in Navajo since 1968. We feel honored and excited to partner with this proud tradition. In our program, which is a collaborative effort between the Navajo Nation, the Indian Health Services, PIH, and Brigham and Women’s Hospital, we have found that we are able to have a positive impact in helping to treat chronic diseases, including diabetes, hypertension, and heart disease and infectious diseases such as Tuberculosis, HIV and Hepatitis C. We are doing this by helping to build and support a robust CHR program of accompaniment that is integrally linked to the clinic and seeks to address the root causes of disease. The reach of community health workers is far, and we are working to see just how far it can go.”
Likhapha Ntlamelle, NP, PIH’s sister organization in Lesotho: “Even in a country like Lesotho that has an unacceptably high burden of TB and HIV (up to 30% in some communities), we are seeing the benefits of including CHWs in our programs. PIH-Lesotho works with the ministry of health to provide care for 7% of the country. Compared to the rest of the country, the patients in these areas have the highest cure rates for TB, the highest survival for HIV, and the least number of women lost to childbirth. People often ask us our secret. We tell them that this is possible because of the double benefit of a revitalized clinic and a high-functioning community health worker cadre that links patients to that clinical system. These CHWs are able to perform at this level because they are well trained, closely supervised, and adequately reimbursed. Our experience shows that in order to get high value outcomes, you have to invest in the people working to achieve those outcomes.”
Junior Bazile, MD, MPH, Abwenzi Pa Za Umoyo (APZU), PIH’s sister organization in Malawi:
“Beyond accompaniment, we have found that community health workers can assist in the TB care delivery value chain in many other ways. Most importantly, our ‘Village Health Workers’ go house-to-house monthly collecting community-level data with our ‘household register.’ This represents a way to do active case finding at the community level. Once the chronic coughers are identified, they are accompanied or referred to Community Sputum Collection Points (CSCPs) for submitting sputum, and then taken to Health Centers depending on their health status and other symptoms that they might present. With this simple but powerful program, we have found hundreds of TB-positive patients. By finding them early, we are able to treat them before they get critically ill or infect others in their community.”
Michael Rich, MD, MPH, PIH Tuberculosis Unit:
“Simply put, well-trained, adequately supervised and humanely reimbursed community health workers will provide incredible benefit across the care delivery value chain for tuberculosis and MDR-TB. We have known this for years, and we have tried to get others to adopt the model. While progress continues to be too slow, we have seen huge change – from the WHO advocating for home-based care to the many ministries of health who have approached us asking for support. The change is starting to take root as we begin to see community health workers being integrated into the health system – trained, paid, and supervised – but most important responsive to the patient’s needs.”
|This piece was compiled by Daniel Palazuelos, MD, MPH. Dan is the Director, Community Health Worker Quality Improvement Task Force at Partners In Health.|
Partners In Health is a Boston-based NGO who’s mission is to provide a preferential option for the poor in health care. By establishing long-term relationships with sister organizations based in settings of poverty, PIH strives to achieve two overarching goals: to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair. At its root, this mission is both medical and moral. It is based on solidarity, rather than charity alone.