Through the USAID-funded Integrated (HIV Effect) Mitigation and Positive Action for Community Transformation (IMPACT) program and with the support of a joint Ministry of Health ART/PMTCT Technical Working Group Task Force, CRS developed and implemented a peer-based task-shifting approach known as the Expert Client model. In this model, HIV-positive Expert Clients were recruited and deployed in 79 health facilities where they provided counseling, psychosocial support and assistance in navigating and accessing HIV care for their HIV-positive peers, including pregnant women and their exposed or infected children. This report includes findings from a formal study on the approach as well as monitoring data, reports, success stories and other literature on the effectiveness of this approach over three years.
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The HIV epidemic has had a tremendous impact on human resources for health in many countries, and Malawi has not been spared. Task-shifting—the intentional delegation of routine functions from highly skilled to less-skilled workers—has been proposed as a feasible alternative for improving HIV service delivery in resource-constrained settings.
Through the USAID-funded Integrated (HIV Effect) Mitigation and Positive Action for Community Transformation (IMPACT) program and with the support of a joint Ministry of Health ART/PMTCT Technical Working Group Task Force, Catholic Relief Services (CRS) developed and implemented a peer-based task-shifting approach known as the Expert Client model. HIV-positive Expert Clients were recruited and trained to provide counseling, psychosocial support and assistance in navigating and accessing HIV care for their HIV-positive peers, including pregnant women and their exposed or infected children.
The Expert Client program operated for three years (2011–2014) through 79 health facilities in 9 districts. Anecdotally, the program has been widely lauded by health care providers, district health managers and patients in HIV care for the extent to which Expert Clients “fit” in the existing HIV care and treatment system. Evidence about the Expert Clients’ contributions improving service delivery is needed to inform crucial human resource management and task-shifting decisions. Specifically, this report is intended to provide insights into the (a) acceptability of this volunteer cadre by salaried HIV service providers, (b) workload implications for HIV service providers when the Expert Client is introduced into the health facility staffing structure, and (c) factors that appear to facilitate and/or hinder Expert Client performance.
A formal study, contracted by CRS and conducted by the Center for Public Health Policy Research and Development (CPHPRD), employed qualitative methods, including in-depth interviews, document review and observations, to obtain data both retrospectively and prospectively. Researchers visited 20 health facilities and conducted 61 in-depth interviews. This report relies heavily on that study, supported by IMPACT program monitoring data, reports, success stories and both published and unpublished literature and videos.
The overall conclusion of the document is that the Expert Client model is well accepted by health care workers (HCWs); at most facilities, Expert Clients are viewed as an integral part of the multi-disciplinary team. While Expert Clients were specifically recruited to assist with providing health education and default tracing, their presence has reduced workload and stress for salaried HIV service providers through the performance of many additional tasks and by simply being “an extra pair of hands.” Though originally positioned to report to the senior Health Surveillance Assistant (HSA), Expert Clients are actually best supported and supervised by the clinical service provider in charge of either HIV services specifically (in bigger facilities) or the facility at large (at smaller health centers).
Furthermore, there is evidence that the deployment of Expert Clients in health facilities has resulted in several benefits, including the following:
- Increased demand for HIV prevention, testing and treatment services
- Streamlined patient flow and service delivery
- Accelerated retrieval of “missed appointments” and improved retention of patients in care
- A strengthened functional referral system between facility and community
- Increased male involvement in prevention of mother-to-child transmission (PMTCT)
Expert Clients serve in areas where the majority of Malawians live and the shortage of skilled service providers is felt most acutely. There is a consensus from all stakeholders that Expert Clients, drawn from within the communities they serve, are available, highly motivated and well-placed—as trained peers—to support HIV service provision. The success of the Expert Client model was, however, moderated by some challenges, including lack of uniforms or common identity, unstandardized and unreliable incentive packages and transportation challenges.
Publication detailsPublisher: Catholic Relief Services (August 2014)
Paper: 36 pages
Posted on August 26, 2014