Implementation

Begin with community

Establishing services in a community begins with an informal (and ongoing) process of surveys and meetings with the local population to find out their specific needs and desires.

Organizational structure

The CHW represents the health center to the community and is an integral part of the medical team, interacting continually with the rest of the staff. It is important that he/she knows the different staff roles and responsibilities in order to direct medical and non-medical issues to the appropriate person.

The number of Community Health Workers

The CHW-to-patient ratio varies from site to site depending on how many CHWs can be recruited or how many CHWs already exist, population density, the logistical demands of the area’s topography, and the types of patients being supported.

Project	CHW:patient ratio
PACT Project Boston*	20 to 25 patients per Health Promoter 7 to 10 patients per DOTS Specialist
Zanmi Lasante Haiti	Up to a maximum of six patients per CHW
PIH-Lesotho	Up to a maximum of five patients per CHW
Socios En Salud Peru	Up to a maximum of five patients per CHW
Inshuti Mu Buzima Rwanda	The ideal ratio is 1 CHW per 6 patients. Each CHW can have a maximum of 8 patients from a maximum of 4 households

*The Health Promoters provide ongoing adherence counseling and support, accompaniment to medical/social service appointments and coordination of care. The DOT Specialists visit patients daily, and help them take their medications.

 

Work schedule

After the initial training, the CHW meets with those patients he/she will support who are undergoing or about to start ARV or TB treatment. The CHW can be chosen by the patient, or, with the patient’s agreement, the CHW may be assigned to a patient depending on where he/she lives.

Ideally, CHW-patient pairings remain stable over the course of treatment/care. While the schedule of visits varies according to the population and geographic spread of the community and their specific health needs, there is a common set of visits that occurs in all the programs.

At the patient’s home

• Once a patient begins AIDS or TB treatment, the CHW visits the patient’s home once a day to administer medications. The CHW should watch the patient take his/her medication. If the patient is having trouble with ART, the CHW visits twice a day to observe both doses.
• CHWs meet with the members of the health center team when the team makes home visits to patients, or when the CHW leader makes unannounced visits to meet with patients and monitor the work of the CHWs.

At the health center

• The CHW accompanies his/her AIDS patients for a consultation with clinical staff two weeks after ART initiation. In some programs, each AIDS patient is assigned to a group based on the starting date of treatment. Each group is assigned a specific day of the week for visits to the health center, thus allowing for coordinated care and monitoring of patient cohorts.
• Additional visits when:
  — A patient is ill and needs to be seen by clinical staff.
  — A CHW identifies a person in the community who shows symptoms of HIV, TB, or other illness.
  — A CHW is assigned to a new patient.
  — The staff at the health center asks to meet with the CHW.
• Twice a month
  — If supervising TB patients, visit the health center to collect TB medicines.
• Once a month
  — Visit the health center to collect ART if supervising AIDS patients.
  — Collect salary.
  — Attend ongoing training and education sessions, CHW meetings, and meetings with health center staff.
  — In some programs:
  º Accompany HIV and TB patients for their monthly consultations.
  º Accompany pregnant women enrolled in the PMTCT program for their monthly consultations.
  º Accompany HIV-positive mothers and their newborns for biweekly consultations.