Malawi’s health service is struggling under the burden of HIV and AIDS and tuberculosis (TB). Its health workforce has only limited capacity to cope due to severe staff shortages, poor salaries and working conditions, high levels of HIV and AIDS-related deaths and chronic absenteeism due to illness among staff.

Without a strong health workforce, community members may have an important role to play in providing HIV and TB care. Médecins Sans Frontières describes an example of community involvement in district level HIV and TB care. The study focuses on Thyolo district, a rural region of southern Malawi with 458,976 inhabitants, of which an estimated 41,000 are living with HIV. It covers a two-year period from January 2003 to December 2004.

A package of community-based activities was designed in close collaboration with community representatives. Volunteers undergo training and those giving home-based care carry a kit with basic drugs and supportive material. In families where individuals are in the advanced stages of HIV, one member is trained as a ‘family caregiver.’ The volunteers are supervised by teams of peer leaders and community nurses, and are remunerated through a variety of incentives. A revolving fund has been created through revenue generated by selling the produce of community farms. Monitoring is conducted through patient cards and activity reports.

Key findings include:

• Community members ran 12 of the 14 voluntary counselling and HIV testing (VCT) sites and conducted 41 percent of all HIV testing in the district.
• By the end of the study period, the community team comprised 465 home-based care (HBC) volunteers, 1,362 family caregivers and 9 community nurses caring for 5,106 people with HIV.
• 2,714 TB patients, of whom 60 percent also had HIV, were followed up on a monthly basis in the community.
• Volunteers screened and referred cases of chronic cough for TB testing. A total of 806 people were referred of which 161 tested positive for TB - indicating that one in five of these individuals have TB.
• Community groups provided care, pre-school activities and vocational training for AIDS orphans, and community vegetable gardens and maize farms provide food for poor individuals and households.
• Community volunteers referred an average of 422 individuals each month to different services at health facilities.

The community in Thyolo is playing a vital role in helping to scale-up HIV and AIDS and TB activities and providing home-based care. Their activities have achieved success in active screening for TB and are likely to have positively influenced health-seeking behaviour. Policy lessons include:

• Community care is likely to yield important savings for health services and both direct and indirect benefits to patients.
• Individuals with chronic coughs should be referred to health facilities.
• Community led activities to mitigate the impact of HIV and AIDS on families and orphans bring dignity and hope to many.
• Communities should not be exploited by simply leaving government responsibilities to communities.
• The skills of district health representatives and collaborating partners in creating the necessary dynamic between health workers and communities to forge collective ownership are crucial.
• A threshold may be reached where volunteers will have too many demands on their time.  Countries with high HIV rates may consider introducing specific ‘remunerated’ community AIDS workers as formal health workers within the public health service in order to sustain community activities without threatening the livelihoods of those involved.

Source(s):
‘How can the community contribute in the fight against HIV/AIDS and tuberculosis? An example from a rural district in Malawi’, Transactions of the Royal Society of Tropical Medicine and Hygiene 100, pages 167-175, by R. Zachariah, R. Teck, L. Buhendwa, S. Labina, C. Chinji, P. Humblet and A.D. Harries, 2006
HINARI subscribers can access the full-text article here. Full document.

Funded by: Médecins Sans Frontières

id21 Research Highlight: 16 June 2006

Further Information:
Rony Zachariah
Médecins sans Frontières
Medical Department
Brussels Operational Center: HIV&TB Operational Research
68 Rue de Gasperich
L-1617
Luxembourg

Tel: +352 332 515
Fax: +352 335 133
Contact the contributor: zachariah@internet.lu

Médecins sans Frontières

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