Task shifting to CHWs is not new

Credentialing CHWs in Support ofCompetency-Based Task Shifting

Dr. Jose M. Zuniga on behalf ofCHW QA and Credentialing Task Team

Task shifting to CHWs is not new

• CHWs are not a new addition to our health systems

• CHWs are associated with the Alma Ata primary care movement, but they long preceded this movement

• CHWs are also known as lay health advisors, promotoras, patient navigators, doulas, community health agents, etc.

What have we learned?

• Elements of ideal CHW program

– Emphasis on priority health needs of the population

– Adequate training, supplies, and supervision; and feasibility of technical competence needs of the population

– Improved accessibility, acceptability, and participation of beneficiaries

• Impact on health services delivery and benefits

– Selection of more efficacious interventions

– Improved quality of care

– Greater coverage and equity, and reduced disparities

Roots of credentialing

• Credential derives from the Latin credere, or “TO PUT TRUST IN”

What do we mean by credentialing?

“A standardized process whereby a skills-based metric is utilized to verify the ability of non-professional health workers to perform certain tasks previously performed by higher-level cadres of health workers, given proper training and supportive supervision.”

TO PUT TRUST IN…

Why are they important?

For the HRH agenda:

• Quality assurance

• Benchmarking

• Incentive

• Driving change

Benefits of CHW credentialing

• Advance legitimacy within health and human services communities

• Improve outcomes related to CHW services

• Help open the door for CHW reimbursement

• Offer assurances to current and potential CHW employers that credentialed CHWs have basic competencies

Potential problems with CHW credentialing

• Erosion of indigenous qualities that make CHWs effective (a critical asset for program success)

– Encourage priority credentialing of current CHWs

– Encourage CHW programs to supplement formal training with training specific to the community served

– Ensure CHW training builds upon CHWs’ affinity with their home communities

• Loss of current non-credentialed CHWs

– Create credentialing credits that currently practicing CHWs can obtain, such as on-the-job training, hours of service, and other life experiences that contribute to effective service delivery

• Other unforeseen problems

– Involve currently practicing CHWs in developing and refining a new credentialing program

CHW QA and Credentialing Task Team

• Co-Chairs

– Adele Webb, ANAC; and Jose M. Zuniga, IAPAC

• Advisors

– David Benton, ICN; and Fadwa Affara, ICN

– Charles Farthing, AAHIVM

– Greg Grevera, ANAC

– Eric Hefer, IAPAC; and Debra Shikati, IAPAC

Objective

To identify generic nomenclatures, competencies, and competency-based credentialing mechanisms as part of a response to assuring the quality of the contribution made by CHWs in support of scaling up access to HIV/AIDS services.

Phase 1

• Preparatory Phase

– Recommend generic nomenclature to identify categories of CHWs

– Recommend a generic list of competency-based tasks by category of CHW

Informed by GWU/SPHHS Regulatory Framework Group, Antwerp/PIH/Harvard Clinical Mapping Teams, WHO resources, IAPAC Clinical Competencies Survey, IMAI clinical care competencies matrices, etc.

Phase 2

• Development Phase

– Identify ways of crafting quality improvement and competency-based credentialing mechanisms by category of CHW

– Submit a draft report on quality improvement and credentialing of CHWs (allowing for country feedback)

– Submit a final suite of reports on quality improvement and credentialing of CHWs

– Present final report in October 2007

Strategically addressing resistance

• Congratulations to WHO and PEPFAR for recognizing the importance of professional associations and engaging with us as stakeholders to make this effort politically viable

• Not surprisingly, many professional associations have historically opposed and resisted the delegation of tasks to other cadres of workers

• Resistance to delegation is not exclusive to “elite doctors”

Times are changing…

• Preliminary results of reveal agreement around shifting 236 of 271 tasks from physicians to nurses

– e.g., prescribe first-line ART, prescribe simultaneous TB and ART (where appropriate), recognize/manage IRIS

• Preliminary results of survey reveal agreement around shifting 76 of 236 tasks from nurses to CHWs

– e.g., basic HIV education, pre-ART counseling, ART support, rapid HIV testing (and confirmatory HIV test)

• Key clause in question: “given adequate training, evaluation (credentialing), and supervision”