YOU ARE HERE:
Executive Summary of Home Care Programme report
| Last updated: 17.05.02 |
Background
Cambodia is reported to have one of the fastest growing HIV prevalence rates in the world. Results from the latest Surveillance Survey (1) indicate that approximately 170,000 Cambodians are now infected with HIV, giving an adult HIV prevalence rate of around 3.5%.
The impact of the rapid spread of the epidemic in Cambodia is drastic. During the year 2000, an estimated 12,000 people with AIDS will seek care and support, thus increasing the pressure on a health care system that currently provides a total of 8,500 beds for all medical conditions (2).
In 1998, as part of the response to the growing HIV/AIDS epidemic, the Cambodian Ministry of Health (MoH) established a partnership with a group of NGOs to develop and implement Cambodia's first HIV/AIDS oriented home care programme. The first year pilot phase was supported by the United Kingdom's Department for International Development (DFID) and the World Health Organization (WHO). Subsequently, the Khmer HIV/AIDS NGO Alliance (KHANA), together with NGOs World Vision and Maryknoll, have supported the MoH and its NGO partners to provide home-based care in Phnom Penh, as well as establishing a pilot home care initiative in Battambang Province.
As KHANA's primary international partner, the International HIV/AIDS Alliance (the Alliance) consulted with the MoH/NCHADS (3) and commissioned this evaluation in February 2000. The evaluation team was led by an independent consultant contracted by the Alliance, and included members from USAID, NCHADS, the National Institute of Public Health and local NGOs. The evaluation was financed by USAID through the Alliance. The purpose of the evaluation was to assess the impact of two years of home care services, to provide an estimate of the programme costs and cost savings to PLHA and their families, and to identify the key components that need to be considered in order to successfully replicate or scale-up this approach.
The AIDS Care Unit of NCHADS is in the process of formulating a strategy for expanding the home care programme to selected Provinces (4). With the agreement of MoH/NCHADS, the findings of this evaluation will be used to guide and shape this expansion strategy.
Footnotes
(1) Report on Sentinel Surveillance in Cambodia, NCHADS/MoH, 1999
(2) UNAIDS (2000) Country Profile, "The HIV/AIDS/STD situation and the national response in the Kingdom of Cambodia", 3rd Edition - February 2000
(3) National Centre for HIV/AIDS Dermatology and STD
(4) Ministry of Health/NCHADS Draft Strategic Plan for HIV/AIDS and STI Prevention and Care in Cambodia. 2001-2003
Impact
The findings of the evaluation clearly demonstrate that the home care programme in Cambodia is having a significant positive impact at a number of levels:
"The Home Care Team only gives us a little help, but it makes a big difference to us; I think it's the difference between life and death" ['retired' sex-worker, age 43, homeless, now married with 3 children; Wat Phnom]
Of the 100 PLHA interviewed in Phnom Penh, 85% said that they were better able to look after themselves, after being visited by the home care team.
83% said that home care visits had helped to improve how much they feel in control of their lives.
72% of PLHA said that home care visits had improved their general well-being and physical health. Many said that, before home care visits began, they were bedridden.
63% of PLHA felt that the home care team had helped to change their outlook on the future.
"Now I am getting visits from the home care team, my health has improved and I am back at work. In fact I am now looking for promotion" [man, age 31, Chamkarmon]
45% of PLHA said that the home care teams had increased their comfort in sharing information about their HIV status with others.
93% of family members of PLHA said the home care team had added to their knowledge of HIV/AIDS, particularly methods of transmission.
More family members (42%) than PLHA (33%) reported reduced discrimination by the community against them as a result of home care visits.
79% of caregivers felt that, following home care team involvement, they could cope better overall with having a PLHA in the family.
"I used to be angry with her because I spent all my time and money looking after her. The home care team has given me encouragement and support. I now understand better and I can care for her. Without them, it would have been impossible" [husband of PLHA, Tuol Kurk]
27% of PLHA (including a number of sex workers) said that they now use condoms as a result of their increased knowledge about HIV transmission.
"After knowing that I am infected, I always ask all the clients to wear a condom" [female sex worker, age 23, Kilometre 9]
The time spent by the Home Care Teams in providing care and welfare support is felt to be important in releasing children from some of the burden of care.
"The home care team help me continue with my business of selling food; before (they started visiting), I couldn't even get out of bed. Without (the HCT) my children would have to leave school to look after me." [widow; age 36; Tonle Bassac]
Costs
The cost of delivering home care services in Cambodia compares favourably both with the cost of providing outpatient services in public health facilities and with the costs of home care programmes in other countries. In addition, it is clear from the evaluation that the home care programme is providing households of PLHA with benefits in terms of financial and time savings.
The evaluation notes that the average cost of providing urban home-based care services is estimated as $9.28 per home care visit, and $14.00 per visit for rural services. Estimates (Bunna & Myers, 1999) indicate that the average costs of hospital outpatient services are $15 per patient-episode. A more realistic comparison with hospital out-patient treatment is provided by the cost associated with addressing the health needs of the patient using home-based care, which the evaluation estimates as $3.71 per home care visit.
It should be noted that the estimated cost per home care visit was determined by totalling all related programme costs together with technical support costs from INGOs and LNGOs (including appropriate proportions of salaries, commodities, transport and overheads). Furthermore, the average cost per home care visit includes the costs of improving the emotional, educational and social well-being of the patient (in addition to improvements in physical well-being). It also includes the costs of prevention and liaison activities in the community and the costs of building both organisational and technical capacity of MoH and NGO partners in the programme.
The financial savings by households are primarily due to changes in the use of traditional healers and in the use of medicines. Families and care-givers reported average savings in time due to home care provision of 3-4 days per month, and cost savings ranging between $0.80 - $1.30 per week. Respondents receiving home care who continue to use traditional healers, reported savings due to decreased and/or more appropriate use of between $5.30 - $10.50 per week.
Key Components
The evaluation identified a set of key components which have contributed significantly to the success of the programme, and which should ideally be incorporated in its expansion. These are outlined below.
This evaluation has noted that strong partnerships exist at a number of levels in the Home Care programme
Such partnerships have enabled scarce resources to be shared, and have ensured that the comparative advantages of each of the players have been effectively utilised. This has undoubtedly contributed to the cost effectiveness of the programme.
Findings from this evaluation indicate that the selection of the right personnel and achieving the right mix of skills and experience in the Home Care Teams is critical to successful team working and has been instrumental in providing a comprehensive service to PLHA and their families.
Launching the project only after adequate and appropriate training, supplemented by responsive, refresher training are key components to maintain professionalism of home care provision.
The Home Care Teams themselves identified the support from community leaders as the most important factor contributing to the successful implementation of their work.
This evaluation found that volunteers are fulfilling a number of important roles in the home care programme, such as referring clients, facilitating access to local authorities and establishing links with community initiatives.
The findings of this evaluation demonstrate the importance of, and demand for a supportive supervisory system to address the management and medical needs of the providers of home-based care.
Participatory reviews, monitoring and external evaluations have helped shape and improve the home care programme.
A flexible and responsive management structure has helped to ensure that the outcomes of reviews are incorporated into the programme.
Consistent technical and financial support has resulted in increased capacity of the NGOs to better manage their Home Care Teams, and of both MoH and NGO staff of the Home Care Teams to better manage their work programmes.
The Home Care Network has played a vital role in helping to ensure co-ordination of support, improve linkages and assist the programme to better meet the increasing demands for improved care and support at low cost.
Key Recommendations
Key Recommendations from the evaluation for improving and expanding the programme are summarised below:
Home Care Network
It is recommended that:
Home Care Activities
It is recommended that:
Referrals, Supervision and Training
It is recommended that:
Volunteer Expansion
It is recommended that:
Programme Expansion
It is recommended that:
Cambodia is reported to have one of the fastest growing HIV prevalence rates in the world. Results from the latest Surveillance Survey (1) indicate that approximately 170,000 Cambodians are now infected with HIV, giving an adult HIV prevalence rate of around 3.5%.
The impact of the rapid spread of the epidemic in Cambodia is drastic. During the year 2000, an estimated 12,000 people with AIDS will seek care and support, thus increasing the pressure on a health care system that currently provides a total of 8,500 beds for all medical conditions (2).
In 1998, as part of the response to the growing HIV/AIDS epidemic, the Cambodian Ministry of Health (MoH) established a partnership with a group of NGOs to develop and implement Cambodia's first HIV/AIDS oriented home care programme. The first year pilot phase was supported by the United Kingdom's Department for International Development (DFID) and the World Health Organization (WHO). Subsequently, the Khmer HIV/AIDS NGO Alliance (KHANA), together with NGOs World Vision and Maryknoll, have supported the MoH and its NGO partners to provide home-based care in Phnom Penh, as well as establishing a pilot home care initiative in Battambang Province.
As KHANA's primary international partner, the International HIV/AIDS Alliance (the Alliance) consulted with the MoH/NCHADS (3) and commissioned this evaluation in February 2000. The evaluation team was led by an independent consultant contracted by the Alliance, and included members from USAID, NCHADS, the National Institute of Public Health and local NGOs. The evaluation was financed by USAID through the Alliance. The purpose of the evaluation was to assess the impact of two years of home care services, to provide an estimate of the programme costs and cost savings to PLHA and their families, and to identify the key components that need to be considered in order to successfully replicate or scale-up this approach.
The AIDS Care Unit of NCHADS is in the process of formulating a strategy for expanding the home care programme to selected Provinces (4). With the agreement of MoH/NCHADS, the findings of this evaluation will be used to guide and shape this expansion strategy.
Footnotes
(1) Report on Sentinel Surveillance in Cambodia, NCHADS/MoH, 1999
(2) UNAIDS (2000) Country Profile, "The HIV/AIDS/STD situation and the national response in the Kingdom of Cambodia", 3rd Edition - February 2000
(3) National Centre for HIV/AIDS Dermatology and STD
(4) Ministry of Health/NCHADS Draft Strategic Plan for HIV/AIDS and STI Prevention and Care in Cambodia. 2001-2003
Impact
The findings of the evaluation clearly demonstrate that the home care programme in Cambodia is having a significant positive impact at a number of levels:
- it is reducing the suffering of people living with HIV/AIDS (PLHA) and improving the quality of their lives and the lives of their families and caregivers;
- it is increasing understanding of HIV/AIDS by helping to forge links between care and prevention and reducing discrimination against PLHA in the community;
- by providing social and economic support, it is helping to empower some of the poorest and most disadvantaged individuals and families in the community.
"The Home Care Team only gives us a little help, but it makes a big difference to us; I think it's the difference between life and death" ['retired' sex-worker, age 43, homeless, now married with 3 children; Wat Phnom]
Of the 100 PLHA interviewed in Phnom Penh, 85% said that they were better able to look after themselves, after being visited by the home care team.
83% said that home care visits had helped to improve how much they feel in control of their lives.
72% of PLHA said that home care visits had improved their general well-being and physical health. Many said that, before home care visits began, they were bedridden.
63% of PLHA felt that the home care team had helped to change their outlook on the future.
"Now I am getting visits from the home care team, my health has improved and I am back at work. In fact I am now looking for promotion" [man, age 31, Chamkarmon]
45% of PLHA said that the home care teams had increased their comfort in sharing information about their HIV status with others.
93% of family members of PLHA said the home care team had added to their knowledge of HIV/AIDS, particularly methods of transmission.
More family members (42%) than PLHA (33%) reported reduced discrimination by the community against them as a result of home care visits.
79% of caregivers felt that, following home care team involvement, they could cope better overall with having a PLHA in the family.
"I used to be angry with her because I spent all my time and money looking after her. The home care team has given me encouragement and support. I now understand better and I can care for her. Without them, it would have been impossible" [husband of PLHA, Tuol Kurk]
27% of PLHA (including a number of sex workers) said that they now use condoms as a result of their increased knowledge about HIV transmission.
"After knowing that I am infected, I always ask all the clients to wear a condom" [female sex worker, age 23, Kilometre 9]
The time spent by the Home Care Teams in providing care and welfare support is felt to be important in releasing children from some of the burden of care.
"The home care team help me continue with my business of selling food; before (they started visiting), I couldn't even get out of bed. Without (the HCT) my children would have to leave school to look after me." [widow; age 36; Tonle Bassac]
Costs
The cost of delivering home care services in Cambodia compares favourably both with the cost of providing outpatient services in public health facilities and with the costs of home care programmes in other countries. In addition, it is clear from the evaluation that the home care programme is providing households of PLHA with benefits in terms of financial and time savings.
The evaluation notes that the average cost of providing urban home-based care services is estimated as $9.28 per home care visit, and $14.00 per visit for rural services. Estimates (Bunna & Myers, 1999) indicate that the average costs of hospital outpatient services are $15 per patient-episode. A more realistic comparison with hospital out-patient treatment is provided by the cost associated with addressing the health needs of the patient using home-based care, which the evaluation estimates as $3.71 per home care visit.
It should be noted that the estimated cost per home care visit was determined by totalling all related programme costs together with technical support costs from INGOs and LNGOs (including appropriate proportions of salaries, commodities, transport and overheads). Furthermore, the average cost per home care visit includes the costs of improving the emotional, educational and social well-being of the patient (in addition to improvements in physical well-being). It also includes the costs of prevention and liaison activities in the community and the costs of building both organisational and technical capacity of MoH and NGO partners in the programme.
The financial savings by households are primarily due to changes in the use of traditional healers and in the use of medicines. Families and care-givers reported average savings in time due to home care provision of 3-4 days per month, and cost savings ranging between $0.80 - $1.30 per week. Respondents receiving home care who continue to use traditional healers, reported savings due to decreased and/or more appropriate use of between $5.30 - $10.50 per week.
Key Components
The evaluation identified a set of key components which have contributed significantly to the success of the programme, and which should ideally be incorporated in its expansion. These are outlined below.
This evaluation has noted that strong partnerships exist at a number of levels in the Home Care programme
- between MoH/NCHADS, KHANA, World Vision and the local NGOs who participate in the programme
- between KHANA and their partner NGOs who support the Home Care Teams
- between the Home Care Teams and the Health Centres at which they are based
- between the government and NGO team members who implement the programme
Such partnerships have enabled scarce resources to be shared, and have ensured that the comparative advantages of each of the players have been effectively utilised. This has undoubtedly contributed to the cost effectiveness of the programme.
Findings from this evaluation indicate that the selection of the right personnel and achieving the right mix of skills and experience in the Home Care Teams is critical to successful team working and has been instrumental in providing a comprehensive service to PLHA and their families.
Launching the project only after adequate and appropriate training, supplemented by responsive, refresher training are key components to maintain professionalism of home care provision.
The Home Care Teams themselves identified the support from community leaders as the most important factor contributing to the successful implementation of their work.
This evaluation found that volunteers are fulfilling a number of important roles in the home care programme, such as referring clients, facilitating access to local authorities and establishing links with community initiatives.
The findings of this evaluation demonstrate the importance of, and demand for a supportive supervisory system to address the management and medical needs of the providers of home-based care.
Participatory reviews, monitoring and external evaluations have helped shape and improve the home care programme.
A flexible and responsive management structure has helped to ensure that the outcomes of reviews are incorporated into the programme.
Consistent technical and financial support has resulted in increased capacity of the NGOs to better manage their Home Care Teams, and of both MoH and NGO staff of the Home Care Teams to better manage their work programmes.
The Home Care Network has played a vital role in helping to ensure co-ordination of support, improve linkages and assist the programme to better meet the increasing demands for improved care and support at low cost.
Key Recommendations
Key Recommendations from the evaluation for improving and expanding the programme are summarised below:
Home Care Network
It is recommended that:
- The Home Care Network Group becomes an autonomous unit with its own resources in order to ensure co-ordination of technical support, improve links with other initiatives and facilitate monitoring.
- The Municipal Health Department AIDS Office begins to assume responsibility for co-ordinating the Home Care Network in Phnom Penh
- Because of its capacity and present involvement in the programme, KHANA is approached to provide technical and financial support to facilitate the expansion and relocation of the Home Care Network Group
Home Care Activities
It is recommended that:
- The Home Care Network Group initiates a review process to clarify and agree strategic priorities for home care activities and to rationalise the roles and responsibilities of the home care teams
- The Home Care Network Group reviews with the HCTs the system of monitoring and reporting patient numbers and team activities
- MoH includes drugs used in Home Care Kits in the Essential Drugs list
- Central Medical Stores initiates steps to provide drugs for Home Care Kits through Health Centres
- The Home Care Network Group initiates a discussion on the criteria for home care provision of prophylactic Bactrim to HIV patients in Cambodia, ensuring that there are clear guidelines for selection and monitoring of patients.
Referrals, Supervision and Training
It is recommended that:
- The Home Care Network Group strengthens the hospital referral system by rein-stating the system of attaching each of the HCTs to one of the main referral hospitals in Phnom Penh.
- Referral hospitals provide supportive supervision to attached HCTs. Supervisors must be resourced and trained in facilitative supervision
- The HCNG implements a schedule of ongoing refresher training and orientations to deal with emerging issues facing HCTs. KHANA, NGOs, MoH and other ministries could act as resources with funding and support through the Home Care Network
- The draft training pack used in initial training is updated and developed into a training resource pack for use when the home care programme is expanded
- The AIDS Care Handbook is translated into English and 1000 copies are printed for distribution to NGOs/IOs
- Pictures from the Home Care Stories are incorporated into a flipchart for teaching purposes by organisations working in the field of AIDS care.
- A module on "Managing Client Expectations" is included as part of the ongoing counselling training provided to HCTs
Volunteer Expansion
It is recommended that:
- The Home Care Teams expand and strengthen Volunteer involvement in the Home Care programme in Phnom Penh and the Provinces
- The maximum number of Volunteers per team is increased from five to ten and Volunteers are encouraged not to work more than 10 days per month
- Volunteers begin to assume more of the social support responsibilities of home care provision, in addition to many of the non-patient-related activities
- The HCTs review and upgrade the skills of the Volunteers, to enable some to provide basic counselling to PLHA and to support peer counselling by PLHA
Programme Expansion
It is recommended that:
- MoH/NCHADS takes the main co-ordinating role in expanding the home care programme in Cambodia
- NCHADS and partners ensure that key components of the home care mode! are incorporated when expanding the programme to the Provinces.
- NCHADS and partners examine the cost-benefits of different models for expansion. Adapting the current model to improve cost-effectiveness in rural areas should be seriously considered.
- MoH/NCHADS and partners support MoH/NGO Home Care Network Groups to co-ordinate activity at Provincial level.
- Donors explore the possibility of trialing a sub-sector-wide approach to funding the home care programme in Cambodia
- The Alliance increases its financial support to KHANA for building local NGO capacity, and maintains its present level of technical support
- The Alliance considers using the Cambodian Home Care Model in other AIDS care programmes that they support.