Task Shifting - Global Recommendations and Guidelines - unaids

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Recommendations on ensuring sustainability Summary of findings Community health workers have the potential to make a significant contribution to increasing access to HIV services under the task shifting approach. Part-time volunteers have an important role to play by offering a limited scope of supplementary support services among their local community. However, if community health workers are to be properly integrated into health systems, and are trained to provide essential services, then their commitment must be sustained through a variety of measures including adequate wages and/or other appropriate and commensurate incentives. Early community health worker programmes assumed a pool of willing volunteers but, in time, lack of payment proved to be a major cause of workforce attrition 64 66 97 . There is virtually no evidence that volunteerism can be sustained for long periods 197 . Most of the evidence reflects low activity rates and high drop-out leading to the ultimate collapse of community health worker programmes where payment, or other appropriate and commensurate incentives, are not adequate 197 198 . For example, in South Africa the lack of payment for community health workers resulted in a high rate of attrition and threatened the effectiveness of the community-based tuberculosis programmes. 199 . One study of community health worker programmes in Sri Lanka concludes that large-scale volunteer programmes will be characterized by high attrition and low activity rates and will only be sustainable under particular enabling conditions 198 . The question of what represents adequate remuneration remains controversial and there is a paucity of evidence to indicate what combinations of incentives, including financial and nonfinancial incentives, are sufficient to motivate and retain community health workers. Some evidence exists to show that the relationship between community health workers and the community they serve is important and that feedback and rewards from the community have an influence on work performance 200 . Nevertheless, the burden of evidence indicates that stipends, travel allowances and other non-financial incentives are not enough to ensure the livelihood of health workers and that the absence of adequate wages will threaten the effectiveness and longterm sustainability of community health worker programmes 65 199 201 . The existing evidence, particularly for resource-constrained countries, overwhelmingly suggests that community health worker programmes are not necessarily less expensive but that they remain a good investment 197 . However, meeting the need for sustainable financing for community health worker positions is a challenge, especially for resource-constrained countries. See further discussion in Recommendation 15. Advantages: • Adequate wages for community health workers help retain human resources for health, especially in rural areas and among marginal communities. • Wages for community health workers may contribute to broader human development and poverty reduction strategies. Uncertainties: • Securing long-term sustainable financing for the health sector is a challenge. Selected examples of experience/additional resources: One of the largest and most successful community health worker programmes can be found in Brazil, where the Brazilian Family Health Programme has been successful in institutionalizing and mainstreaming community participation. Community health workers have been integrated into health services and are paid wages 202 203 . 36 In Ethiopia and Malawi community health workers have been trained and deployed to support a nationwide increase in access to HIV and other health services. These cadres have been fully integrated into the national system for service delivery as regular employees. They receive payment from the government and these costs are included in the national health budgets of both countries Annex a .
Recommendations on ensuring sustainability Recommendation 15 Countries and donors should ensure that task shifting plans are appropriately costed and adequately financed so that the services are sustainable. Comment: Budgeting and financing should take into account both one-time and recurrent costs. These should include resources for essential support services such as training, supervision, referral systems, retention measures and adequate wages for new and existing cadres and the anticipated need for essential equipment, health-care supplies and physical infrastructure. Budgeting and finance should also take into account the likely rise in demand levels for all health services that may result from increased user access through task shifting. The Ministry of Health will need to work with appropriate partners, such as the Ministry of Finance, the Ministry of Labour and the Ministry of Education, and the civil service, donors, international financial institutions, the non-state sector and others involved in the funding and implementation of health services, to secure sustainable financing for task shifting activities. Summary of findings Task shifting should not be viewed as a cost-cutting strategy. In fact, a successful task shifting programme which decentralizes and expands access to HIV services at the community level is likely to increase the total number of health-service users, including increasing the demand for other health services. Therefore, task shifting plans must be financed adequately to take these considerations into account. Clearly, if the scale-up of HIV services is to be sustainable, and if task shifting is to help increase access to other health services, the plan may require new and additional resources. Significant investment will be needed to support training and a range of supportive mechanisms including quality assurance. A variety of financial and non-financial incentives may be needed to reward and retain health workers as part of the task shifting approach. New and additional physical infrastructure may be needed to accommodate an expanded workforce and increased patient flow. Poor working conditions lead to attrition of the health workforce. Therefore, if task shifting is to be sustained it must be accompanied by strategies for safe workplaces and adequate equipment and supplies such as gloves, soap and antiseptics. In many countries, logistical systems for supplying rural and peri-urban communities will need to be strengthened to ensure the availability of essential supplies. Countries will still need to increase the overall numbers of specialist health workers such as doctors and nurses hand in hand with the implementation of the task shifting approach. In a small number of countries there is also a need for financing arrangements that can absorb skilled doctors and nurses who are currently unemployed or underemployed due to a combination of factors, including fiscal constraints. An important consideration for financing a task shifting approach is related to the overall objective of moving towards universal access to HIV services. The need for treatment and its related costs will escalate for years to come as people living with HIV/AIDS become chronic patients in need of lifelong care. Financing systems will need to be developed within the particular macroeconomic, sociocultural and political context of each country and geared towards country-specific priorities 204 . However, 37
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Page 5 and 6: Contents Preface...................
Page 7 and 8: summary of recommendations Summary
Page 9 and 10: Summary of recommendations E. Recom
Page 11 and 12: ackground The plan is an important
Page 13 and 14: scope Scope These recommendations a
Page 15 and 16: summary of methods Summary of Metho
Page 17 and 18: summary of methods A total of 167 e
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Page 29 and 30: Recommendations on ensuring quality
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Page 55 and 56: Annex 1 Annex 1 HIV clinical tasks
Page 57 and 58: Annex 1 Manage STIs X X X Assess fa
Page 59 and 60: Annex 1 Provide co-trimoxazole prop
Page 61 and 62: Annex 1 e. Supervision MD NPC N CHW
Page 63 and 64: Annex 1 b. Manage TB Coinfection MD
Page 65 and 66: Annex 1 Provide supportive care to
Page 67 and 68: Annex 1 Counsel on special nutritio
Page 69 and 70: ANNEX 2 1 WHO. The World Health Rep
Page 71 and 72: ANNEX 2 94 Akakpo M. Processus d’
Page 73 and 74: ANNEX 2 180 Ensor T, Savelyeva L. I
Page 75 and 76: ANNEX 3 shifting approach for the d
Page 77 and 78: ANNEX 3 The country studies were de
Page 79 and 80: annex 3 Additional information A to
Page 81 and 82: annex 4 Learning by doing Above all
Page 83 and 84: annex 6 Annex 6 Definitions Accredi
Page 85 and 86: annex 6 Registration Official recor
Page 87 and 88: annex 7 Dr Kevin De Cock, Director,
Page 89: annex 7 Dr Adele Webb, Executive Di
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Health Systems and Services (HSS) W
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Task Shifting - Global Recommendations and Guidelines - unaids

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