1. Community Mobilization & Expanding Community-based Service Delivery Bactrin Killingo MD ITPC IAS 18th June 2011 Rome Italy

2. Setting the Scene What’s happening out there?

3. Community Participation … Community Participation …Bottom up approach … the power & contribution of the beneficiaries of care… Community-driven development (CDD) An approach that aims to give control over planning decisions and resources to community groups … operat(ing) on the principles of local empowerment, participatory governance, demand- responsiveness, administrative autonomy, greater downward accountability, and enhanced local capacity. (World Bank) Community Systems Community-led structures and mechanisms used by communities through which community members and community based organisations and groups interact, coordinate and deliver their responses to the challenges and needs affecting their communities. Community Response …social dynamics & relationships

4. AwarenessTestingDiagnosis Treatment Initiation Adherence & Follow up Clinical Outcomes Opportunities to Test Partner Communication & Approval Family Support & Disclosure Delivery in a Clinic Self Efficacy Social Capital & Networks Perception of Risk Accurate Local Understanding Transport & Time Costs Motivation vs Fear of Results Fear of abandonment & Violence Perception of Service Quality STIGMA Depression & Ill Health HIV Treatment Cascade Borrowed from Joanna Busza – IAS 2011

5. POC Comprehensive Testing & Treating

6. POC Community Treatment Groups

7. PPTCT Cascade Of 100 HIV+ Mothers entering the Program Those who attended ANC Clinic 92% Those who Counseled & Tested for HIV, CD4 75% Those who get ARVs (Pre & Postnatal) 50% 34 68 92 Source: CIFF analysis based on presentation by P Barker at WHO PMTCT consultation meeting Nov 2008

8. Community Mobilization The Why, What Who..

9. Community Mobilization Why & For What? Increase Demand for HIV Treatment & Prevention Services – Know HIV Status – Treatment literate persons – Timely referrals – Regular community led Monitoring & Follow up Increase Supply for HIV Treatment & Prevention Services – Additional/alternative Human resource – Advocacy for policy change – Advocacy for change in programming & facility based service delivery

10. Beneficiary of Care IndividualFamily Organized PLHIV Groups Private Entities Cultural Entities Admin Bodies Local Admin MPs Civic Leaders Support Groups CBOs Networks NGOs (For/Not For Profit) Businesses Religious Orgs Council of Elders Who should be Mobilized?

11. Expanding Community Based Service Delivery The Possibilities…

12. Why Community Led/Based Services Key Unique Contribution Communities have the understanding, experience & skill Access Community service entities have reach to compliment facility based health service provision Ownership Of the people, By the people for the people Acceptance Community led services are likely to have more takers

13. Community consciousness of their role in service delivery Community reorganizing to be in tune with new paradigm (Tx 2.0) – Treatment literacy programes – Point of Care community led linked services Testing; mobile, house to house etc Treatment access information Treatment referral Treatment care groups – Mozambique example Country Policy review to adopt & implement the CSS framework Resourcing community led service delivery How to Expand Community Based Services

14. Figure 2: Community action and results for health Activities/services for communities (Community) (Community) Systems develop & manage that they use to deliver Health Actors Community Actors Outputs Health outcomes Other outcomes Impacts on health Resulting in: which in turn contribute to that lead to Source: GFATM CSS Framework 2010

15. Table 1. HIV services and activities that CBOs are uniquely placed to deliver TreatmentPreventionAdvocacy Adherence support Testing and counselling Treatment literacy Linkage to care/support services Linkages to harm reduction services Management of health and psycho-social needs following testing Disclosure support Treatment delivery (a treatment extension role for community organizations) Case management Nutritional support Prevention of vertical transmission Harm reduction services (syringe exchange, opioid substitution therapy [OST], etc.) Sexuality education Sexual and reproductive health and rights awareness Condom distribution PrEP (pre-exposure prophylaxis) education Education on TB infection control Contact tracing/partner notification support Client negotiation, collectivization, peer outreach skills for sex workers Promotion of male circumcision Post-exposure prophylaxis (PEP) for sexual assault survivors Monitoring and accountability (health systems, government responses, rights abuses, quality of services) Quality assurance of health services Anti-stigma, anti- discrimination, and decriminalization efforts(legal support, law reform, lobbying) Policy analysis around access to and development of essential medicines Ensuring the meaningful involvement of people living with AIDS in policy and programme development

16. Community consciousness of role in service delivery Community reorganizing to be in tune with new paradigm (Tx 2.0) – Treatment literacy programes – Point of Care community led linked services Testing, counseling, disclosure support; mobile, house to house etc Treatment access information Treatment referral Case management through Treatment care groups – MSF Mozambique & AMPATH Kenya Models* Psycho-social & Nutritional support Country Policy review to adopt & implement the CSS framework Resourcing community led service delivery How to Expand Community Based Services *Distribution of Antiretroviral Treatment through Self‐Forming Groups of Patients in Tete Province, Mozambique (Decroo 2011) *Wools-Kaloustian KK, Sidle JE, Selke HM, Vedanthan R, Kemboi EK, Boit LJ, Jebet VT, Carroll AE, Tierney WM, Kimaiyo S. A model for extending antiretroviral care beyond the rural health center. J Int AIDS Soc. 2009 Sep; 12(1):22

17. Individual/Family Centered Voluntary Community led Comprehensive Prevention Package PPTCT Optimal Treatment Easy to use Affordable Uninterrupted Refer Educate  Initiation  POC Monitoring  Support System(s) Community Expanded Services Test TreatPrevent

18. How to Expand Community Based Services Community consciousness of role in service delivery Community reorganizing to be in tune with new paradigm (Tx 2.0) – Treatment literacy programes – Point of Care community led linked services Testing; mobile, house to house etc Treatment access information Treatment referral Treatment care groups – Mozambique example Country Policy review to adopt & implement the CSS framework Resourcing community led service delivery – Local & Global Innovative Mechanisms & Frameworks

19. Community Expanded Services Test TreatPrevent Individual/Family Centered Voluntary Community led Comprehensive Prevention Package PTCT/PMTCT Optimal Treatment Easy to use Affordable Uninterrupted Refer Educate Leadership Stewardship Supportive Policy & Operational Plans Resources Man Money Moment  Initiation  POC Monitoring  Support System(s)

20. Ahsante Sana