Abstract
Low-income countries with high HIV/AIDS burdens in sub-Saharan Africa must deal with severe shortages of qualified human resources for health. This situation has triggered the renewed interest in community health workers, as they may play an important role in scaling-up antiretroviral treatment for HIV/AIDS by taking over a number of tasks from the professional health workers. Currently, a wide variety of community health workers are active in many antiretroviral treatment delivery sites.This article investigates whether present community health worker programmes for antiretroviral treatment are taking into account the lessons learnt from past experiences with community health worker programmes in primary health care and to what extent they are seizing the new antiretroviral treatment-specific opportunities.Based on a desk review of multi-purpose community health worker programmes for primary health care and of recent experiences with antiretroviral treatment-related community health workers, we developed an analytic framework of 10 criteria: eight conditions for successful large-scale antiretroviral treatment-related community health worker programmes and two antiretroviral treatment-specific opportunities.Our appraisal of six community health worker programmes, which we identified during field work in Ethiopia, Malawi and Uganda in 2007, shows that while some lessons from the past have been learnt, others are not being sufficiently considered and antiretroviral treatment-specific opportunities are not being sufficiently seized.In particular, all programmes have learnt the lesson that without adequate remuneration, community health workers cannot be retained in the long term. Yet we contend that the apparently insufficient attention to issues such as quality supervision and continuous training will lead to decreasing quality of the programmes over time. The life experience of people living with HIV/AIDS is still a relatively neglected asset, even though it may give antiretroviral treatment-related community health worker programmes better chances of success than their predecessors and may be crucially important for adherence and retention in large-scale antiretroviral treatment programmes.Community health workers as a community-based extension of health services are essential for antiretroviral treatment scale-up and comprehensive primary health care. The renewed attention to community health workers is thus very welcome, but the scale-up of community health worker programmes runs a high risk of neglecting the necessary quality criteria if it is not aligned with broader health systems strengthening. To achieve universal access to antiretroviral treatment, this is of paramount importance and should receive urgent attention.
Highlights
Despite significant progress in scaling up antiretroviral treatment (ART) in low- and middle-income countries in recent years, the gap between the need for ART and the numbers currently receiving it is still wide in most of subSaharan Africa [1,2].The health care systems of low-income countries with high HIV prevalence have been struggling to provide even basic health care to the population, let alone to deal with the additional burden of scaling up ART [3,4,5]
While estimations of human resources for health (HRH) needs for scaling up ART show wide variations depending on contexts and programme variables [8], there is an enormous mismatch between the HRH needs of the prevalent ART delivery models and the HRH supplies in the health systems in most of sub-Saharan Africa [9,10,11]
In this article we focus on task shifting for ART to community health workers (CHWs), asking how far they have taken on board the lessons learnt from past experiences with CHW programmes for primary health care and how far they are seizing the new HIV/AIDS-specific opportunities
Summary
Despite significant progress in scaling up antiretroviral treatment (ART) in low- and middle-income countries in recent years, the gap between the need for ART and the numbers currently receiving it is still wide in most of subSaharan Africa [1,2]. It is becoming ever more obvious that for scaling up ART to the millions in need, the roles of professional health care workers must be redesigned and the pool Based on such examples and on experiences with chronic care in high-income countries, we hold that in addition to the eight general conditions for successful CHW programmes, there are two more specific opportunities for ART-related CHW programmes, completing our list of ten issues: 9. They receive a monthly salary of about USD 350 and a daily lunch allowance of about USD 3 With their high level of education, they are fairly atypical CHWs. In Malawi we identified the following six types of CHWs involved in HIV-related activities: community health workers, community care providers, VCT community counsellors, volunteers trained at the health facilities, HBC volunteers and health surveillance assistants (HSAs). The involvement of PLHAs in tasks such as adherence counselling and defaulter training has not been considered, even though it may be one of the most important elements for achieving good results in these two crucial programme aspects
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