University of Zambia Medical Library

Alleviating the Impact of HIV/AIDS in Zambia: Home and Community Based Care
(AIDS in Zambia Bibliography #203-18)

(#203) "AIDS Care and Prevention in a Zambian Rural Community"
Campbell, I.D. (1988) unpublished
Geographical area: Chikankata, Province; Keywords: Home based care, counselling, health care delivery; Location: UNICEF

Summary:
The management of AIDS at Chikankata has followed a pattern of home based care, with hospital intervention where required. Whilst adhering to the concept that prevention is the main priority, Chikankata has explored the principle of patient care being the best method of mounting a prevention programme, as well as expressing appropriate and compassionate support. From a patient care focus emerges the opportunity for prevention through education, prevention through contact tracing, and also community surveillance where possible. This strategy for management has been implemented through the establishment of a specific unit, which will soon develop into a specific department for AIDS management with the hospital and the local community.

Comments:

• It is obvious that decentralisation of management is vital to reducing bed pressure. It is also recognised that decentralisation without management is not management at all. It is neglect.
• HIV infection is contributing to the need for further hospital beds at Chikankata Hospital, despite increasingly rigid discharge criteria and active home based care policy.
• The main impact of AIDS in the Chikankata catchment area is on young families.
• There are two main questions in AIDS management. The first is the question of how HIV-positive people are found, and the second question is how HIV-positive people are influenced in terms of behaviour. The answers to the second question will arise out of the Chikankata model of management and other models that will develop in the African settings.
• The key element to successful home based care is positively motivated staff who have the ability to motivate patients and their families into thinking in terms of quality of life. The following benefits, given that capacity, become obvious:
  • The reduction in bed pressure enables other programmes to continue and develop;
  • Family support is strengthened;
  • The patient is included in the village community;
  • Preventive education occurs through caring for people. Transmission of information is "upwards" into the wider community. A multi-faceted approach to care and prevention is needed in a national sense, placing maximum reliance upon dialogue, implemented through home care teams.
  • Contact tracing is easy to achieve.
  • Home based care is cheaper.

It is estimated that 35 admissions were prevented throughout the year which would have cost more than all the home based visits for the whole year. Without a home based care policy, there would be an increased hospitalisation period for the average HIV patient, as well as increased admissions. It is clear that if home based care can be organised there is likely to be significant cost benefit to the hospital.

Conclusions:

• If AIDS is to be prevented it must be managed.
• This means caring for people with HIV and those without it and finding opportunity for education and contact tracing by all possible means, which must include reliance on dialogue with individuals, families and communities, in their home environments.
• Setting up an AIDS care unit or department, containing a home based care team approach, is likely to prove the best method of administration and AIDS control in the African context. It will, at the very least, provide the best means of defining the problem, and a mechanism for implementing the various control strategies.
• The problem is that the virus is in the village. The ultimate solution lies in an attitude of "self-help" by village and family leaders, who will take the initiative for the survival of their extended families.

(#204) "Review of six HIV/AIDS programmes in Uganda and Zambia"
World Health Organization (1989) Global Programme on AIDS, Geneva
Geographical area: Regional ; Keywords: Home based care, households, evaluation; Location: UNICEF

Objectives:

• To describe selected home care programmes for persons with HIV infections and their families in Africa and summarise the similarities and differences between the programmes.
• To identify the human, physical and financial resources needed in the implementation of selected home care programmes.
• To assess selected home care programmes on specific evaluation criteria, primary health care principles and sustainability.
• To discuss the programmes in the context of national AIDS programmes and non-governmental organisations.

Method:
Six programmes in two countries (Zambia and Uganda) were selected using the following criteria: provision of home care to people with HIV infection and their families was an essential feature of the services provided; and the programmes had been in operation for approximately two years.

Information was collected through: 56 individual interviews with key persons including facilitators (initiators, policy makers, supporters); administrators; service deliverers (doctors, nurses, social workers, patients, volunteers, etc); four group interviews with staff; 16 individual/group interviews with recipients of care and their families; observations from 51 patient situations in the home/prison and 13 patient situations in a clinic; observations (visits) at six home care teams' offices, three clinics, four hospital wards, three day rooms, one yoga room and three workshops for clients and staff; and, documentary material.

Results:

• Four of the six home care programmes described are hospital-initiated and hospital-based.
• The reasons given for starting the home care programmes were most often concerned with ensuring future bed capacity for patients with diseases other than HIV infection, and the belief that people prefer to die at home and that it is possible through home care to provide quality care and efficient health education to families and communities.
• The objective of all the home care programmes is to provide quality care (physical, psychological, social and in some cases spiritual care) in the home to persons with HIV infection and AIDS as well as their families.
• Most programmes emphasise the importance of combining the provision of care with counselling and education. Some programmes include the wider community as a target group.
• In the home care programmes, the intention is to see AIDS not only in relation to the health problems of certain individuals but also in its specific African family, cultural, social and economic context.
• All the programmes offer home care exclusively to persons and families affected by HIV infection and, as a rule, there is no intention to tackle health problems in the families visited that are not HIV-related.

Conclusions:

• Home care has been shown to be a viable way of meeting needs of patients with HIV infection and their families.
• Services for persons with HIV infection have been organised in new and efficient ways.
• The home care programmes have not covered all the persons with HIV infection in need of service in their area.
• The programmes have depended almost exclusively on external funding.

(#205) " AIDS Management: An integrated approach"
Campbell, I., Williams, G., (1990), Strategies for Hope, No. 3., 1990.
Geographical area: Chikankata, Southern Province; Keywords: Home based care, households ; Location: UNICEF

AIDS is now a major cause of morbidity and mortality in East, Central and Southern Africa. Recent surveys in several countries in this region show HIV seroprevalence rates of 5 to 20 per cent among the adult urban population and even higher rates among some high risk groups such as female prostitutes. In rural areas prevalence rates are lower but already significant and on the increase. In the absence of a cure of HIV infection, the prospects for the 1990s are grim indeed. Hundreds of thousands of young adults - most of them parents - will suffer long and chronic illness ending in premature death. Many thousands of babies will be borne infected with HIV and will suffer repeated illness before dying within the first two or three years after birth. Medical services, already inadequate for existing needs, will become severely over - stretched. Hospitals in particular will be unable to deal with the huge case load of patients with HIV/AIDS in need of medical and nursing care. In some African countries this crisis point has already been reached.

For health care providers, the challenge is to provide people with HIV/AIDS with at least a bare minimum of medical and nursing care, as well as psychological and social support. Official health services, in their present form, are unable to meet this challenge. A small number of non -governmental organisation, however, have developed new forms of AIDS control incorporating home- care and support for people with HIV/AIDS and their families. These pioneering efforts provide a basis of practical experience from which useful lessons may be drawn by programme managers and policy makers alike. The Salvation Army Hospital at Chikankata, in Zambia's Southern Province, has developed a model of AIDS control which combines home-based care with hospital intervention where required. Chikankata has explored the principle of patient care as the starting point for prevention through contact tracing, information, education, and counselling at the levels of the individual, the family and the community.

(#206) "Home and community care in Zambia: the Zambian experience"
Chela, C., Siankanga, Z., (1990) AIDS, Vol 5 (suppl 1). pp. S157-S161.
Geographical area: National; Keywords: Home based care, households, health care delivery; Location: UNICEF

Objectives:
To describe selected home care programmes for persons with HIV infection and their families in Zambia. To discuss the various home care models existing in Zambia.

Method:
Information was collected through interviews with home care programme personnel; personnel experiences in running the home care programme; and through documentary material.

Results:

• . All the programmes developed from a concern for the increasing number of patients and the need to care for them in the simplest and most effective way given the resources available.
• Home-based care is an appropriate and acceptable means of looking after patients with symptomatic HIV disease as it reduces the number of patients coming for treatment at the hospital.
• In 57 per cent of new families seen, the breadwinner was infected with HIV, almost half of whom are single mothers. There are serious implications for the remaining spouse and orphans. Strategies to care for these children need to be resolved before the problem becomes unmanageable.
• Patients continue to seek the help of traditional healers while receiving home care, and are prepared to achieve symptomatic relief using traditional remedies. Links with traditional healers should be encouraged in order to solicit heir help with remedies which prove effective and with anti-AIDS activities in general.
• The spiritual aspect of home care should not be overlooked since most of the patients are religious.

Conclusions:
Home care has shown to be a viable way of meeting the needs of the patients with HIV infection and their families.

(#207) "Concept transfer through integrated AIDS management seminars; a one-year review"
Bailey, B., Bodwell, S., Towani, C., Malama, M., Radder, A., (1991) Paper presented to the VIIth International Conference on AIDS, Florence, 1991.
Geographical area: Chikankata, Southern Province; Keywords: Health care delivery, home based care; Location: unknown

Objectives:
To describe a process curriculum approach to transferring concepts of integrated AIDS management which allows participants to develop context specific programme responses. To report on 12 seminars held over a one year period with participation by health workers and others from 45 institutions/organisations in Zambia and the Africa region.

Method:
Seminar participants are categorised by occupation, type of institution/organisation represented, and country or region represented. Curriculum is described and process reports from seminars are reviewed. Participants develop action plans for their own contexts during the seminar. These are presented for approximately 45 contexts. On-site follow-up visits with 15 institutions review the progress of action plan implementation and team development.

Results:
Programme descriptions from Botswana, Tanzania, Malawi and Zambia are given, which demonstrate an application of the following concepts:

• an interdisciplinary team approach;
• exploration of community strengths as the key to behaviour change for care, prevention and control of AIDS;
• programme development for sustainability (of people, programme and finances).

Conclusions:
Medical and paramedical workers, along with educators, counsellors, social workers and administrators, have been enabled to develop skills in community facilitation and problem solving, and are using these skills and concepts to develop AIDS programme responses in their own settings.

(#208) "The Response of HIV/AIDS Patients and Their Families to Home Care in Lusaka Urban"
Mwiinga, M.S. (1991) unpublished
Geographical area: Lusaka ; Keywords: Home based care, health care delivery, households; Location: UNZA Medical Library

As the number of HIV seropositive patients increased it was envisaged that more and more patients would be nursed in their own homes in the years to come, therefore, decentralisation of case management was inevitable. In response to this demand, a Home care programme was commenced in Zambia in 1988 with the aim of providing ancillary services to AIDS patients at home. A sample of 25 HIV/AIDS patients and 25 of their relatives were selected to participate and a structured interview schedule was prepared to collect data.

The study design was a non-intervention descriptive type. Results showed a positive response to home care among patients for the following reasons: desire for constant family attention, choice of food, relaxed house atmosphere, opportunity to seek other forms of treatment outside hospital and cost effectiveness. It was recommended that efforts to make home care acceptable by both patients and care-givers should be enhanced and future studies should concern themselves with the concerns and information needs of primary care-givers involved in home care of AIDS patients.

(#209) "Direct cost of AIDS case management in Zambia"
Hira, S., Sunkutu, R., Wadhawan, D., Mamtani, H., (1993) Paper presented to the IXth International Conference on AIDS, Berlin, 1993.
Geographical area: Lusaka; Keywords: ; Location: unknown

Objective:
To estimate direct cost incurred by the health sector to provide clinical management to patients with HIV-related disease and AIDS.

Methods:
The annul cost of health care of each patient with HIV related disease /AIDS was estimated. Cost analysis of University Teaching Hospital (UTH) was used because it was readily available. Although UTH is a tertiary level hospital, it functions like a general hospital for Lusaka. The cost was categorised under following items: Professional staff, diagnostic test/ procedures, drugs, inpatients, outpatients, and home based care.

Conclusions:
Considering that Zambia has 500,000 infected people, the estimates are that 50,000 have AIDS, and another 150,000 have HIV related disease. The annual cost of clinical care of AIDS patients is $27.1 million and that for HIV related- disease is 27.3 million. This places unprecedented burden on health services in Zambia.

(#210) "Study Tour of AIDS Programmes in Zambia, Uganda and Kenya 1993"
Smart, R., Fincham, R. (eds) (1993) Nairobi: UNICEF
Geographical area: Southern Province; Keywords: Health education, home based care, counselling, awareness, churches; Location: UNICEF

Objectives:
To help develop the capacity of local primary health care (PHC), development of and AIDS personnel to address the growing threat of AIDS to individuals and groups at risk - specifically women and children - through the implementation of appropriate strategies for training, counselling and care.

Methods: Site visits to Zambia, Uganda and Kenya.

Results:

• Evidence of increasing numbers of people with HIV infection and AIDS does not necessarily prompt behaviour change, despite high levels of awareness and information about the disease.
• Different models of child care are necessary for different situations, but where possible orphaned children should be kept within the family and community as opposed to placing them in orphanage type environments.
• Terminology in AIDS and related fields is far from being uniform, e.g., "street children" in South Africa and Zambia. Common understanding and/or definitions of terms should be sought.
• The process of instigating and developing AIDS initiatives is difficult and the often romanticised notion of excellent programmes "elsewhere" seldom lives up to expectations when compared to their representation in literature which often aspirations rather than achievements.
• The usage of billboards can be a salutary device for promoting AIDS awareness, but the message depicted should be chosen with care and the effectiveness of the technique subject to evaluation.
• Working for change will require innovative methodologies such as taxi dialogues, clinic salting and street drama production. These may prove more useful than traditional ways of information.
• The perceived age of onset of sexual behaviour may represent an unwillingness to confront the root cause of the problem, which is the need for explicit sex education for the young.
• In terms of behaviour modification, the present generation of adults and teenagers may be a "lost generation", suggesting that scarce resources in situations of fiscal prioritisation should focus on the very young. There is however a responsibility to provide information for all people which must not be denied.
• The positioning of AIDS work within a policy framework requires careful consideration. National programmes need to be decentralised and imbue themselves with an inter-linked regional, sub-regional and community ethic.
• Counselling must be provided "out, in the community" with support and supervision from appropriate centres. In this way resources are established where they are most needed - in peripheral urban communities and in dispersed settlements and rural areas.
• Counselling offers an opportunity for behaviour change.
• Counsellor stress and burn-out indicates the need for in-built support systems, as well as guidelines for minimum standards for training and supervision of counsellors.
• Many courses given at present do not necessarily empower people who take them because of power inequalities within relationships and structural constraints such as lack of access to sufficient and appropriate resources.
• The church needs to make conscious and strategic policy decisions regarding AIDS. Denial of the realities of the people's lives which place them at risk of infection and the role which the Church is forced to assume in caring for those infected and affected is paradoxical. AIDS as a sin syndrome needs to be confronted.
• In the designing of programmes and the provision of care and counselling as a set of minimum, appropriate standards must be enacted.
• A realistic approach to the impending epidemic is to prepare people to live in a world with AIDS. Teachers must acquire bereavement skills and be able to advocate coping strategies for the management of the social problems arising from AIDS. Teaching society to live with the dying is important - the teacher as undertaker is an important concept.
• AIDS must be viewed as a component of PHC and development and not the other way round. This is a major shift for AIDS organisations and it does not imply a necessary reduction in resources allocated to the AIDS work but rather reflects the importance of allowing AIDS to take a relevant position within this wider framework.

Conclusions:

• There are significant benefits to such a study tour, especially the opportunity of seeing initiatives " on the ground " and being able to extensively debate the issues within a group whose members have very varied experiences.
• The Study Tour should be seen as part of a process. This report will, it is hoped, precipitate discussion around a number of issues, lessons learned will be implemented within existing programmes and proposals written for new projects.

(#211) "A consultancy Report: Evaluation of the Home based Care Programme of the Churches Medical Association of Zambia (CMAZ) "
Macwang'i, M., Nangawe R., Ngcongco R.N. (1993), unpublished
Geographical area: National; Keywords: ; Location: Institute of African Studies, UNZA

The CMAZ AIDS care and prevention programme has been implemented over a period of four years. The objectives of the programme have been to create greater awareness of HIV and AIDS among communities, develop home based care and training of human resources. The purpose of the review is to evaluate the implementation and impact of the CMAZ Home Based Care Programme. This review was commissioned by the CMAZ in 1993. Its main objectives were: to determine the extent to which the home based care concept has been put into practice; to examine programme management procedures both at the CMAZ secretariat and at member institutions; to determine the impact of the programme on communities and health institutions; and to review the programme's standing in relation to other activities within the framework of the National AIDS Prevention and Control programme.

To conduct this review, multiple complementary methods were used to collect the information. These were: record review, interviews/discussions, observations, field visits and continuous dialogue with key individuals at CMAZ secretariat. The findings indicate that in terms of its programme achievements, CMAZ has spear-headed the implementation and acceptance of HBC concept by government, non-government and communities. The programme has made AIDS information and education available to rural communities which have been isolated and not accessed through commonly used media.

Significant activity levels were observed in the areas of Home based Care (HBC) comprising home visits, patients and family counselling, community counselling and public education concerning HIV/AIDS. Significant achievement has been observed in the CMAZ supported institutions for the provision of vital service to AIDS patients within the framework of hospital to home based care approach. The successes at a community level include voluntary testing of HIV is now being sought by individuals because of increasing awareness of AIDS; active involvement of HIV-positive persons in community education and patient support; CHWS are used as community counselling agents and TBAs as home care providers; schools have established Anti-AIDS clubs whose activities are to integrate with child to child programmes; discussions about determinant factors of HIV in the communities and families; and involvement of traditional leaders and other key people in the communities represents a significant achievement in the behavioural change aspect.

Although measures have been achieved in line with AIDS awareness and care, inadequate knowledge about HIV/AIDS among the community and HBC providers is still evident. Inadequate integration of HIV/AIDS prevention and care activities into other health activities and involvement of some key sectors (e.g. Agriculture, Community Development and Social Services) in HBC limited the degree of HIV/AIDS prevention and control integration into other social and health care programmes. The suggestion on integrated HIV/AIDS home based care programme is emphasised. The need for human resource capacity building and donor support are required.

(#212) "Management seminars; strategy for AIDS care and prevention"
Siame, D.C., Mwilu, R., Chaava, T., Chela, C., Sulwe, C., (1993) Paper presented to the IXth International Conference on AIDS, Berlin, 1993.
Geographical area: Chikankata, Southern Province; Keywords: Home based care, health care delivery, counselling; Location: Kara Counselling

From July 1989, the Chikankata AIDS Care and Prevention Department has been conducting a five-day seminar each month. The seminar is primarily for health professionals and others from within Zambia and the region who are currently involved in or need to start AIDS care and prevention programmes. The seminar provides an integrative approach covering such disciplines as counselling, clinical care, education, pastoral care and administration. The content is based on the practical, field-based AIDS care and prevention programmes at Chikankata. This paper highlights the impact the seminars have had for the period 1989 to date, based on seminar evaluations. It concludes by encouraging those involved in AIDS care and prevention programmes to consider setting up simple management seminars.

(#213) "Study to Determine the Attitudes of HIV/AIDS patients and their Families towards the Establishment of a Hospice Care Centre in Lusaka Urban "
Ndubu M. (1993) unpublished
Geographical area: Lusaka; Keywords: Health care delivery, hospice; Location: UNZA Medical library, WHO

This study seeks to determine the attitudes of HIV/AIDS clients and their family members towards the establishment of hospice centre in Lusaka Urban. A descriptive survey was designed to tour six home-based care centres and an interview schedule was used to collect data on attitudes towards home based care centres. A sample size of 30 HIV/AIDS clients aged between 21-40+ years were randomly selected and recruited from the study population (75 per cent). Results reveal that the majority of clients were willing to use hospice centres. A similar situation was indicated by family members to make use of hospice centres. The use of hospice centres proved to be cost effective and accessible for both clients and family members. The need for expansion of such services is recommended.

(#214) "Feasibility study of Mobilising Community Resources for HIV/AIDS Patients in Kalingalinga Compound, Lusaka"
Kabwe, R.S. (1993), unpublished
Geographical area: Lusaka; Keywords: Home based care, households; Location: UNZA Medical Library

A community based survey seeks to determine the feasibility of mobilising community resources for HIV/AIDS patients in Kalingalinga Compound. A sample size of 50 female and male household heads aged between 19 - 42 years were selected using random sampling technique. The determined sample consisted of both men and women. A semi structured interview schedule was used to collect information on knowledge of the existence of AIDS patients in their homes; availability of resources and willingness to mobilise resources for HIV/AIDS patients. The findings reveal that most people are aware of the need for them to provide assistance to AIDS patients (84 per cent), as the resources readily available were manpower (48 per cent) and spiritual care (32 per cent).

This is because these patients are cared for by their relatives.The most inadequate are financial resources and infrastructure. The willingness to mobilise and promote resources is highly appreciated by respondents (96 per cent). The majority of groups and individuals identified are women (64 per cent) followed by Catholics representing 54 per cent. This indicates that women and religious groups (e.g. Catholics) are key people in the community for resource mobilisation and provision. The determination of the community people to accept the needs of AIDS patients is impressive in this study and possibilities to mobilise resources for HIV/AIDS patients within the communities are quite evident.

(#215) "An Evaluation study of Hope House; An innovative way of Looking After HIV Individuals,' Lusaka"
Nyaunde H. (1993), Unpublished
Geographical area: Lusaka ; Keywords: Counselling, health care delivery, evaluation; Location: UNZA Medical Library, WHO

The study aims at assessing the effectiveness of the services offered to HIV clients by Hope House, Kara Counselling. A sample size of 25 (five staff and 20 clients) was determined and data collected using self administered questionnaire for staff and semi structured questionnaire for clients. The questions were on knowledge about AIDS, counselling services, attitudes of staff towards clients, acceptance of the clients by staff, income general activities and satisfaction of the project. The research findings suggest that both the staff and clients had the basic knowledge of AIDS. The type of services offered and general set-up of the facility are more acceptable and conducive to suit the needs of the clients. The expansion of such facility was highly recommended.

(#216) "A review of the effectiveness and cost of home based care programmes for patients with HIV/AIDS in Zambia"
Banda, M.A., (1993) Paper presented at the VIIIth International Conference on AIDS in Africa, Marrakech, 1993.
Geographical area: National ; Keywords: Home based care, cost, health care delivery, ; Location: unknown

Introduction:
A review of home based care programmes for HIV/AIDS patients in Zambia was conducted in 1992 with the view of determining the effectiveness and ascertain the cost of those programmes.

Objectives:
The review had three main objectives namely:

• To identify and characterise emerging models of home based care implementation,
• To determine the effectiveness of home care programmes and
• To consider the costs involved in running the programmes.

Methods:
Seven home based care programmes which were better established than most other were selected for the review. The selected programmes were at Chikankata, Chikuni and Monze hospitals in the Southern Province of the country; St. Francis and Nyanje hospitals in the Eastern Province, Chilonga in the Northern Province, and Lusaka. Published and unpublished information on the home care programmes were examined, discussions were held with programme managers, a questionnaire was sent to the programmes, experience of field visits and data from an on-going study on cost on hospital care for HIV/AIDS patients were utilised.

Results:
Three models of implementing home based care were identified. Two of the models operated in the rural area while the third operated only in an urban area. The levels of acceptance of home care patients were generally high. They ranged between 65 per cent and 95 per cent. A range of clinical conditions associated with HIV/AIDS were attended to by the home care programmes. Services provided to patients and communities also include counselling, health education, food supplements, spiritual assistance and other forms of material assistance. The proportion of patients who were seen on home care ranged from 18 per cent to 60 per cent of all patients seen at the hospitals. The direct costs of running home care programmes, besides diagnostics and treatment, varied from 3,016 US dollars for Chikuni in 1991 to 10,900 US dollars for St. Francis in the same year. Per capita cost for home care for Monze was 0.18 US dollars while per capita of hospital stay was 1.70 US dollars.

Conclusion:
Home care possesses a lot of potential for reducing the congestion at health institutions, reducing the cost of care and yet providing patients with a wide range of services besides clinical care. Home based care appeared to be cheaper than hospital admission for HIV/AIDS-related conditions. However, it is possible that direct costs might increase with more patients getting into home care. Indirect costs for home care could be determined, but could have a lot of effect on families and on other health programmes.

(#217) "Costing and evaluating home based care in Zambia"
Msiska, R., Chela, C., Mwanza, A., Chaava, T., Martin, A., et al. (1994) Paper presented to the Xth International Conference on AIDS, Yokohama, 1994.
Geographical area: National; Keywords: Costs, home based care, health care delivery.; Location: NASTLP

Introduction:
In Zambia, bed capacity has remained constant since 1984. Admission of AIDS patients has increased by more than 15 per cent annually. Our response to the additional burden has been the development of several models of Home Based Care (HBC) programmes. These models vary widely in philosophy, infrastructure, cost, productivity, and outcome. Yet policy-makers have no empirical information about the different models to support investment decisions.

Objectives:
The overall aim is to describe and analyse five models in order to understand alternative approaches and resulting costs and impact.

Methods:
A cost-effectiveness analysis of five home care programmes was carried out. Net direct costs and productivity measures were computed and several comparable effectiveness variables measured using exploratory techniques including structured interviews, focus group discussions and time and motion studies.

Preliminary results:
The five models are systematically described and presented in a conceptual framework used to carry out the cost-effectiveness study. While all five models are compared in the analysis, two distinct models are emphasised:

• Community Based Home Based Care: these are community initiatives predominantly run by lay persons in the community on a voluntary basis with support from community organisations, church and health facilities.
• Hospital Based Home Care: this is an outreach initiative by paid hospital staff who seek collaboration at community level.

Programme element	Outreach Home Care approach average per programme. N=4	Community Based Home Care approach. N=1
Cost per visit (US$)	0.43	0.14
Coverage (No of clients)	65	200
Average duration per visit (minutes)	30	120
Transport cost (p.a) (US$)	19485.29	1274. 51
Supplies (p.a) (US$)	5851.12	2601.20

Conclusions:
Outreach based home care costs more at any given service as compared to community based home care. The largest cost item in the hospital based home care is transport, followed by supplies and staff salaries. In the community based home care, the largest cost component was supplies, followed by transport. The average duration per visit was longer with the community-based home care as compared to hospital based home care which may reflect cultural appropriateness and assistance in household activities.

This study indicates that costs can be reduced by decentralising home acre as near as possible to the community for an amount affordable by the communities with linked support. A possibility to increase coverage for care for AIDS patients is through community based home care. The challenge, therefore, to communities and programme designers is how does one arouse the interest and commitment in home care within a context of increasing demands for better health and development.

(#218) "Technical assistance: Enabling programme sustainability - The Chikankata Hospital, Zambia "
Hatwiinda, J., Siame, D., Mwilu, R., Winters, D., (1994) Paper presented to the Xth International Conference on AIDS, Yokohama, 1994.
Geographical area: Chikankata, Southern Province; Keywords: Health care delivery, home based care, ; Location: CMAZ

Objective:
To determine why some AIDS Care and Prevention programmes are floundering even when sending multiple participants to our AIDS Management Training Seminars (AMTS). To assess how we could help them.

Method:
Evaluations were conducted at participating centers in Zambia and neighbouring countries to assess the effectiveness of our AMTS. Questionnaires were distributed to discover felt needs and problems with programme implementation.

Results:
90 per cent of the respondents indicated the need for assistance at their locations to resolve problems and implement projects. 80 per cent of former AMTS participants were still involved with programmes that had not progressed past the infancy stages.

Conclusions:
Despite the successful establishment of AIDS Care and Prevention programmes following participation in our AMTS, participants encountered difficulties with programme implementation and sustainability. This expressed need can be met by offering "on location" technical assistance.

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