|Community Home-Based Care in Resource-Limited Settings - A Framework for Action (WHO - OMS, 2002, 100 p.)|
|Roles and responsibilities for CHBC at the national, district and local levels|
CHBC is applied in practice at the community level. The culture of the community organization and its norms, standards and leadership play an important role in the CHBC programme. Strategies must therefore be developed that promote effective leadership and mobilize community action in planning and implementing CHBC. This community involvement includes the participation of caregivers, ill people, health and social service workers, community volunteers, community members and influential leaders. This means that all community members associated with CHBC should be involved in the initiation, responsiveness and sustainability of the programme. In addition, this programme should be integrated into existing community services and agencies. In most settings, this integration will be with local health facilities.
Since the four sections of this document are designed to interrelate with one another, the final section highlights a community development framework together with checklists for the establishment and maintenance of CHBC. This community development framework complements the issues raised in this section. In addition, the following questions for local-level responsibilities are organized to reflect the essential elements of CHBC identified in the third section of this document.
· Have strategies been developed to attend to the physical care of ill people?
· Have strategies been developed to attend to the emotional and spiritual needs of ill people, caregivers and members of the CHBC team?
· Have strategies been developed to promote effective palliative care?
· Have strategies been developed to support effective orphan care?
Continuum of care
· How can cooperation and collaboration be encouraged between NGOs, faith-based organizations, other community-based organizations and members of the CHBC team?
· Have strategies been developed to ensure equal access to CHBC?
· How can the waiver system (or free services for poor and destitute people) be administered equitably and transparently?
· Have mechanisms been developed for record-keeping and referral?
· How can CHBC be integrated into the local health care system?
· Have other resources for referring ill people and family members been identified?
· Have mechanisms been developed so that members of the CHBC can communicate with other community resources?
· Have educational strategies and materials been developed or adapted for training ill people, family caregivers and members of the CHBC team?
· Who should administer and monitor these educational programmes?
· Have community education projects been established?
Supplies and equipment
· Has a list of essential drugs for CHBC been developed?
· Has a list of equipment and supplies for CHBC been developed?
· Has a list for CHBC kits been developed?
· Has the ordering system been developed to ensure a continuous supply of the necessary equipment and supplies?
· Who will manage supplies, equipment and CHBC kits?
· Has a location been found for CHBC management and for storage?
· Who will manage and supervise CHBC? How will these supervisors be recruited, educated and supported?
· Has an effective staff mix been developed for CHBC?
· Who will recruit and train paid and voluntary health and social service workers?
· Have strategies been developed to promote staff retention?
CASE STUDY 1
Collaboration, partnerships and referral: a district-focused multisectoral approach to CHBC in Tanzania
The national government organizes CHBC in Tanzania. However, the government has developed a multisectoral approach to ensure that ill people and families have access to a continuum of care. To that end, the government has formed a ministerial department in which all ministries associated with care, prevention and support for people with HIV/AIDS and other chronic illnesses and their families are represented. Moreover, NGOs, faith-based organizations and other community groups are also represented at this ministerial level. However, collaboration, partnerships and referrals have become a district-level responsibility to ensure holistic care for ill people and their families. This is done by developing district management teams, assessing and listing community resources, providing education for effective coordination and referral and hiring a CHBC coordinator to oversee comprehensive care for ill people and their families and support while respecting the confidentiality of ill people and their families.
Developing district management teams. A CHBC management team has been formed in each district throughout Tanzania. This team is headed by the district medical officer and involves partnerships with local health centres, NGOs, faith-based organizations, traditional healers and other community organizations and groups. This team is responsible for developing a district resource list that includes a description and the location of community resources and the services they provide. In addition, the district management team is responsible for developing an action plan to ensure holistic management and home care for people with HIV/AIDS and other chronic illnesses.
Avoiding duplications and gaps in service. As the district management team develops a resource list, they can assess whether there are any gaps in comprehensive care across a continuum and identify duplication. For example, if an ill person and family require psychosocial support and counselling, a member of the district management team can refer this family to the appropriate resource. However, ill people requiring medical attention are referred to a medical centre or hospital. Should gaps in service be identified, the district management team is responsible for developing services to meet that need.
Developing coordination. Providing comprehensive care across a continuum of services requires effective coordination. The Tanzanian government realized that such coordination would require further training of health and social service personnel. Training sessions were therefore provided to train trainers at the district level health centres. These trainers, in turn, train community health workers, volunteers, ill people and family members. This establishes the knowledge and skills of how to coordinate comprehensive care across a continuum. To ensure effective coordination, each district hospital has a CHBC coordinator. The role of the coordinator is to facilitate and support this coordination and referral process.
Respecting confidentiality. Referral forms for ill people have been developed and are now being used by the resources and services within the district management coordination system. However, although this system of referral and coordination is comprehensive, confidentiality is still respected and maintained. This is accomplished by ensuring a confidential record-keeping system and by promoting the confidentiality of ill people and their families throughout the system of care.
This comprehensive continuum of care was established recently in Tanzania to meet the growing needs of people with HIV/AIDS and other chronic illnesses living at home and their families. Such an approach has helped to provide a system of referral and coordination in which CHBC is an integral component within a continuum of care framework.
Source: Zebina Msumi; e-mail firstname.lastname@example.org.
Financing and sustainability
· How can effective community leadership be encouraged and promoted?
· How can innovation and creativity be encouraged through community mobilization, including creative sources of local CHBC funding?
· How can people associated with CHBC become active participants in developing and managing local CHBC programmes?
· How can available resources and accumulated experience be identified and used as a starting-point for further development?
· Who will manage CHBC funds? Who will be responsible for preparing and monitoring the budget?
· How will these funds be equitably and transparently allocated?
Monitoring and evaluation
· What strategies have been developed for quality assurance?
· Have the criteria for informal evaluation been developed?
· Who is responsible for informal evaluation?
· Who is responsible for formal evaluation? Have plans for formal evaluation been made?
· How will the necessary change be monitored?
Communication across different levels
· How can communication between the local, district and national levels of administration be established and effectively maintained?
The impact of CHBC will be experienced at the local level, especially in the homes of ill people and caregivers. However, the national (central) and district (middle management) levels will probably decide regulations, policy guidelines, administration and overall management. Using the four interrelating sections of this document as a whole is therefore essential. In addition, effective communication between all levels of administration and within different government agencies is important in establishing and maintaining effective and responsive CHBC. Box 3 provides an overview of the important features of local- or community-level roles and responsibilities for CHBC.
Box 3. Local-level roles and responsibilities for CHBC
Providing physical, emotional and spiritual care and support Establishing a continuum of care
Developing mechanisms for educating the ill people, caregivers and CHBC teams
Ensuring adequate supplies and equipment for the CHBC programme
Recruiting and retaining an adequate and appropriate mix of staff
Developing effective methods for monitoring and evaluating CHBC
Addressing the financing and sustainability of CHBC
Creating intersectoral communication between various levels of administration
In conclusion, this second section provides a framework to determine the administration and management issues for CHBC programmes. As such, this section should be viewed in relation to the first section on policy formation and the next two sections on the essential elements of CHBC and community action to establish and maintain CHBC programmes. The purpose of presenting this framework is to provide decision-makers with tools to determine the division of the roles and responsibilities for CHBC between national, district and local administration.
These two young Tanzanian orphans are being cared for by their grandparents. In some communities, whole families are dying and elderly people are increasingly left without support and with the responsibility for bringing up their grandchildren.
Doctors and nurses from the Central Hospital of Maputo in Mozambique make weekly home care visits to AIDS patients who are too weak to go to hospital, like this 25-year-old woman.