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Home Care - 7.2 Expansion models
7.2 Expansion Models
Although the home care model described in this report works efficiently and cost-effectively in Phnom Penh, there are dangers in simply transferring the model wholesale to the Provinces. The previous section highlighted the key components which contribute to the success of the model, and which should be replicated in the expansion.
However, one major difference between Phnom Penh and most of the Provinces, is the large distance between villages, health centres and hospitals, and between the villages themselves. As shown by the Battambang pilot, using professional HCTs, with the same cadres of staff as in Phnom Penh, to visit patients in outlying villages is neither efficient nor cost-effective. It is estimated (see section 6.6 of this report) that the existing model in Battambang is only providing between 10-15% coverage in the district.
Furthermore, cost estimates discussed earlier in the report (section 4.4.3) indicate that the cost of providing services in rural areas using this model can be significantly higher than the cost of providing similar services in urban areas.
It is clear that HIV infection is well-established and has reached the general population in every province (39). Given the current prevalence rate, it is estimated that a typical Operational District (O.D.) will have between 1000-2000 PLHA. Using the present Battambang pilot/Phnom Penh model, where the rural HCT has a patient load of 60 per month, this would indicate that between 10-25 HCTs per O.D. would be necessary to give the degree of coverage presently provided in Phnom Penh. Given the limited infrastructure and human resources in the provinces, and the uncertainty of financial support, it is unlikely that this approach will be feasible.
There are a number of alternative partnership and funding options for expansion of the programme to the provinces. Based on the findings of this evaluation, four possibilities are suggested below:
Option 1
Adapt and scale up the existing model to selected provinces, maintaining the current key components:
Based on lessons learned from the rural pilot, the adaptation could conceivably involve:
It is estimated that the above adaptations to the rural environment will enable up to 1,200 patients to be visited per O.D, an average of 3 times a month.
Option 2
The model outlined above would be employed, but all funding would be provided through the government, rather than through NGOs. It should be noted that whilst this option is entirely possible, it has not yet been tried. It is likely that external Technical Assistance would still be required to co-ordinate the Network and provide training to Home Care staff.
Option 3
Again, use the above model, but with government funding the government component, whilst the NGO component is funded from non-government sources. Again, while this mechanism is possible, it has not been tested.
Option 4
Although the evaluation has shown that government/NGO partnerships are key to the success of this approach, ministries other than the Ministry of Health (for example the Ministry of Women’s & Veterans’ Affairs) could be involved as part or even the whole of the government component. It is likely that there would still be a requirement for external technical assistance.
A key evaluation recommendation for the existing urban Home Care Network to become an independently resourced group should also apply to future Provincial Home Care Networks, however funded. The Provincial AIDS Office (PAO) is well placed to host the Network, perhaps with joint co-ordinators from the PAO itself and an NGO. It is reasonable to assume that technical support will be required from both NCHADS and perhaps an external source, such as KHANA, to ensure that Provincial Networks are well established and resourced. In addition, it is likely that Provincial Home Care Networks will need technical assistance to enable them to respond to the training needs of the home care staff, and in establishing effective referral and monitoring systems.
The options outlined above all draw on the key components reviewed in the previous section of this report, namely:
It should be reiterated that if this model is to operate effectively, it is important that the other key components outlined in the previous section are also put in place. These include:
These are only a few of a number of possible options for consideration. The costs associated with these models will need to be carefully estimated. However, it is likely that they will be significantly less than those associated with simply replicating the present model throughout the O.D.
The evaluation team recommends that the cost-benefits of these, and other models, should be examined. Given the diversity of resources and capacities of various players in different Provinces it would be wrong to be prescriptive at this stage. It may be that different models are needed for different Provinces, and that the existing Phnom Penh model would operate effective in urban centres in other Provinces.
It is recommended that NCHADS and partners examine the cost-benefits of different models for expansion. Different models may be needed for different locations.
It is recommended that NCHADS and partners ensure that key components are included when expanding the programme to the Provinces.
Footnotes
(39) Consensus workshop on HIV/AIDS in Cambodia, Phnom Penh, 1999 op.cit.
Although the home care model described in this report works efficiently and cost-effectively in Phnom Penh, there are dangers in simply transferring the model wholesale to the Provinces. The previous section highlighted the key components which contribute to the success of the model, and which should be replicated in the expansion.
However, one major difference between Phnom Penh and most of the Provinces, is the large distance between villages, health centres and hospitals, and between the villages themselves. As shown by the Battambang pilot, using professional HCTs, with the same cadres of staff as in Phnom Penh, to visit patients in outlying villages is neither efficient nor cost-effective. It is estimated (see section 6.6 of this report) that the existing model in Battambang is only providing between 10-15% coverage in the district.
Furthermore, cost estimates discussed earlier in the report (section 4.4.3) indicate that the cost of providing services in rural areas using this model can be significantly higher than the cost of providing similar services in urban areas.
It is clear that HIV infection is well-established and has reached the general population in every province (39). Given the current prevalence rate, it is estimated that a typical Operational District (O.D.) will have between 1000-2000 PLHA. Using the present Battambang pilot/Phnom Penh model, where the rural HCT has a patient load of 60 per month, this would indicate that between 10-25 HCTs per O.D. would be necessary to give the degree of coverage presently provided in Phnom Penh. Given the limited infrastructure and human resources in the provinces, and the uncertainty of financial support, it is unlikely that this approach will be feasible.
There are a number of alternative partnership and funding options for expansion of the programme to the provinces. Based on the findings of this evaluation, four possibilities are suggested below:
Option 1
Adapt and scale up the existing model to selected provinces, maintaining the current key components:
- Home Care Team structure consisting of government nurses, NGO staff and community volunteers.
- co-ordination by a representative network group, through the Provincial AIDS Office
- funding through NGOs with donor support
- external Technical Assistance to co-ordinate the network
Based on lessons learned from the rural pilot, the adaptation could conceivably involve:
- A 4-person District-level Home Care Team based at the Referral Hospital (Operational District Level) rather than Health Centre (Commune Level)
- The District-level HCT liases directly with 2 person Commune HCTs based at each Health Centre
- Commune HCTs liase with Village Home Care Volunteers (1 or 2 per village), who will become the grass-roots providers of home-based care.
It is estimated that the above adaptations to the rural environment will enable up to 1,200 patients to be visited per O.D, an average of 3 times a month.
Option 2
The model outlined above would be employed, but all funding would be provided through the government, rather than through NGOs. It should be noted that whilst this option is entirely possible, it has not yet been tried. It is likely that external Technical Assistance would still be required to co-ordinate the Network and provide training to Home Care staff.
Option 3
Again, use the above model, but with government funding the government component, whilst the NGO component is funded from non-government sources. Again, while this mechanism is possible, it has not been tested.
Option 4
Although the evaluation has shown that government/NGO partnerships are key to the success of this approach, ministries other than the Ministry of Health (for example the Ministry of Women’s & Veterans’ Affairs) could be involved as part or even the whole of the government component. It is likely that there would still be a requirement for external technical assistance.
A key evaluation recommendation for the existing urban Home Care Network to become an independently resourced group should also apply to future Provincial Home Care Networks, however funded. The Provincial AIDS Office (PAO) is well placed to host the Network, perhaps with joint co-ordinators from the PAO itself and an NGO. It is reasonable to assume that technical support will be required from both NCHADS and perhaps an external source, such as KHANA, to ensure that Provincial Networks are well established and resourced. In addition, it is likely that Provincial Home Care Networks will need technical assistance to enable them to respond to the training needs of the home care staff, and in establishing effective referral and monitoring systems.
The options outlined above all draw on the key components reviewed in the previous section of this report, namely:
- good partnerships (between MoH, NGOs/CBOs and possibly other ministries)
- selective team formation and composition
- expansion and integration of volunteers (who are now likely to be the primary providers of home-based care)
- closer community participation (the home care programme is now located within the community, fostering greater ownership and involvement)
- a supportive supervisory system (operating at three levels, and converging with the existing MoH supervisory system)
- a supportive home care network (drawing on resources of key partners throughout the province).
It should be reiterated that if this model is to operate effectively, it is important that the other key components outlined in the previous section are also put in place. These include:
- appropriate initial and ongoing training
- adequate technical and financial resources and support
- ongoing reviews, monitoring and evaluation
These are only a few of a number of possible options for consideration. The costs associated with these models will need to be carefully estimated. However, it is likely that they will be significantly less than those associated with simply replicating the present model throughout the O.D.
The evaluation team recommends that the cost-benefits of these, and other models, should be examined. Given the diversity of resources and capacities of various players in different Provinces it would be wrong to be prescriptive at this stage. It may be that different models are needed for different Provinces, and that the existing Phnom Penh model would operate effective in urban centres in other Provinces.
It is recommended that NCHADS and partners examine the cost-benefits of different models for expansion. Different models may be needed for different locations.
It is recommended that NCHADS and partners ensure that key components are included when expanding the programme to the Provinces.
Footnotes
(39) Consensus workshop on HIV/AIDS in Cambodia, Phnom Penh, 1999 op.cit.