Upload
buitu
View
213
Download
0
Embed Size (px)
Citation preview
O B MHLONGO
DEPUTY DIRECTOR: PMTCT
13 JUNE 2017
COMMUNITY FOLLOW UP, REFERRAL
AND LINKAGE SYSTEM USING
COMMUNITY CARE GIVERS
8TH SA AIDS CONFERENCE
INTRODUCTION AND
BACKGROUND
�KwaZulu-Natal (KZN)province is the second
populous following Gauteng, with 11 079 700
million people which represents 19.8% of the South
African Population. ( Mid – year Population estimate
2016 Stats SA)
�About 30, 1% of the population in the country is
aged younger than 15 years and approximately 23,
0% (3, 86 million) lives in KwaZulu-Natal province
alone, which is higher than Gauteng (3.43 million)
(Stats SA mid year estimates 2014)
�KZN has10 district municipalities plus 1 Metro
INTRODUCTION AND
BACKGROUND
�KZN currently have 9 624 Community Care
Givers (CCGs) and 492 CCG Supervisors
�There are 828 wards in the province – with
varying CCG coverage.
�CCG’s conduct household visits on daily basis,
even though not all wards are covered, but the
majority of the rural ones do have acceptable
coverage.
INTRODUCTION AND
BACKGROUND
�During the MDGs count down to 2015; KZN
embarked on Siyanqoba Campaign, which had 5
Pillars and the fourth Pillar was – Linking Pregnant
and Postnatal women with CCGs
� CCG linkage forms were developed..\CCGs\CCG
home visit form edits.doc
�PCR linkage form was developed in 2015 following
implementation of Birth PCR testing..\PMTCT
Survey\eMTCT Lat Mile\Consultative Meeting
PNC\HOSPITAL FACILITY PCR TEST FORM.doc version
3.doc
WHY CCG LINKAGE
�Readily available cadre of health care workers at
community level
�Need to improve/intensify post natal care within 3-6
days.
�Minimizing loss to follow up; in particular – HIV
exposed and PCR positive babies
�Early infant diagnosis is useless without tracking of
these infants and linkage to care
�Existing link between the Clinics and CCGs
�Reasonable community coverage
PROCESS OF LINKING CCGS: ANC
Step 1: Pregnant women are linked to the CCG’s/
WBOT.
�Write the name and contact details (cellphone
number) of the CCG on the cover page of the
maternity case record.
�Attach home visit form to maternity case record.
�Inform the mother about the linkage.
PROCESS OF LINKING CCGS: ANC
Step 2: Link CCG/ WBOT to mother
�Insert form/paper with patient’s contact details:
names, cell phone numbers, and their address into
the CCG’s pigeon hole at the clinic.
�CCG’s should open their pigeon holes weekly to
retrieve the new mothers.
�CCG’s does home visits within a week and complete
home visit forms, and submit report weekly at the
clinic.
PROCESS OF LINKING CCGS: PNC
Step 1:
�Attach home visit form to the PNC discharge form at the
time of discharge
�Find out from the mother if she will attend the same
facility Postnatally, agree on the date for the PNC visit
�Complete the PCR Linkage form for HIV Positive clients
�The form is faxed, taken to the clinic by transport for
specimens or PHC Supervisor.
� It reaches the follow up clinic before the client arrives
PROCESS OF LINKING CCGS: PNC
Step 2:
�Ward clerk compile a list of all clients that have
delivered that will be discharged: names and contact of
their CCG’s.
�She uses Catchment Area CCG list to identify local CCG.
�PRO/OM collects details of the discharged mothers
from the ward.
�PRO/PHC notifies the CCG’s of their patient’s discharge
Link CCG/ WBOT to mother
�The list of the discharged mothers is also shared with
the PHC Supervisors
PROCESS OF LINKING CCGS: PNC
�Step 3:
�CCG visit mother and baby within 2 days after discharge
from hospital.
�CCG complete the home visit form that was attached in
the post natal ward.
�She/he reports back at the clinic on weekly basis, unless
if there is an emergency
�NB! CCG visit is not recorded as post-natal care visit,
however CCGs encourage & remind mothers to go for 3-
6 day post-natal care.
EMTCT LAST MILE LINKAGES
�PCR near real time monitoring – weekly NHLS Reports.
�PCR positives, Indeterminate and rejected results
communicated with the PHC facility
�EMTCT Gaps Questionnaire shared with all PHC
facilities..\PMTCT Survey\eMTCT Last Mile\EMTCT
Gaps seven questionaire.doc
�OM or Champion at the clinic traces the mother /baby
pair if not yet visited the clinic
�Weekly Teleconference with all the district coordinators
giving feedback on previous week NHLS Action files
EMTCT LAST MILE LINKAGES
�Mother baby/pair that has not visited the clinic,
following telephonic tracking – CCG contacted to trace.
�Community structures in some wards are actively
involved including Ward Councilors ( OSS)
Conclusion
21 21
�It is possible to Eliminate Mother to Child
Transmission of HIV using multi-pronged
interventions : community interventions are critical
�CCGs are a critical link between communities and
health facilities to enable our children to…………
YES…WE CAN ELIMINATE……EVEN IF THE ROAD
AHEAD IS STEEP!
START
FREESTAY
FREE
AIDS
FREE
AKNOWLEDGEMENTS
22 22
�National Department of Health and KZN Department
of Health
�Ms. Pinky Phungula
�District PMTCT & MCWH Coordinators
�UNICEF SA
�NHLS/ NICD
�Developmental Partners