The Community Referral Agent Model
Community Referral Agent Model for Linking People To HIV Services
Using the Community Referral Agent (CRA) model, BRIDGE II trained CRAs to conduct community-based needs assessments for HIV services, and provided individuals and families with information and referrals for those services available within BRIDGE II implementation districts.
Prior to beginning their work, CRAs received a 5-day training. This training was guided by the Resource Manual for Community Referral Agents in Malawi produced by BRIDGE II’s implementing partner, the International HIV/AIDS Alliance (IHAA). The training enabled the CRAs to: understand their duties and responsibilities; address the psycho-social and physiological health needs of their clients; understand challenges that vulnerable groups (orphans, individuals and families in situations of poverty, child-headed households) encounter and the type of referral that they might need; enhance their interpersonal communication skills; and learn about best practices for assessing client needs and selecting referral services. The training also included basic information on HIV prevention, care, and treatment. CRAs were trained to refer clients for several HIV and sexual health-related services, including HIV testing, prevention of mother-to-child transmission of HIV, family planning and antenatal care, voluntary medical male circumcision, treatment of sexually transmitted infections, family planning and how and where to access condoms. The CRAs-in-training also received a copy of the Resource Manual for Community Referral Agents in Malawi, booklets containing referral forms needed to refer clients to HIV services, a referral directory of places where clients could access HIV and health services, CRA t-shirts, bags and bicycles to support their work.
The implementation of the CRA model began with door-to-door visits to identify clients that could benefit from HIV services. During these visits, CRAs conducted an assessment of individual and family HIV service needs using documented guidelines laid out in their Resource Manual. CRAs explained to individuals and families why HIV testing, prevention, and treatment services were relevant and beneficial; where to find the services within the area or district; what days and times services were available; and whether a fee was required for each recommended service. Then they discussed with clients what they should expect when visiting a service provider and what they should do to get the most out of their visit. The CRAs completed and provided their clients with forms indicating the client’s age, sex, marital status and the service required. The referral forms were in triplicate: the CRA’s copy remained in the referral booklet, and the client and service provider’s copies were given to the client to take to the service provider. Upon arrival at the service point, the client presented the two copies to the service provider who signed on both of them after attending to the client and providing the HIV or health service. The client took back his or her copy and left the service provider copy at the service point where they were stored in a box until the end of the month when the CRA came to collect them. The service provider forms were a means of feedback to the CRA on the proportion of people who went and accessed service against the total number of people whom he or she sent as indicated in his or her referral booklet. The service providers’ forms were later sent to BRIDGE II offices alongside CRA monthly reports as evidence that the reported number of people indeed accessed services.
CRAs compiled and submitted monthly CRA reports to BRIDGE II and District Health Offices, highlighting the number of people whom they referred in a particular month and the number of people who accessed services, disaggregated by gender. The reports also included challenges encountered by the CRAs in the previous month, along with suggestions on how to address and remedy those challenges. Quarterly supervisory visits, conducted by IHAA, helped the CRAs to find solutions to common problems in addition to providing a forum for sharing experiences and success stories. The project also facilitated quarterly stakeholder meetings that brought together CRA representatives, service providers, District AIDS Coordinators, Social Welfare Officers, representatives from the District Health Offices and any other concerned office to interface on the work of CRAs. These gatherings helped in addressing some bottlenecks in referral work and facilitated the resolution of the root causes of those bottlenecks.