PAKISTAN – Harnessing the Government Lady Health Worker Programme to increase community-based active TB case-finding CASE STUDY Implementation dates Demonstration phase: April 2017–October 2018 Scale-up under Global Fund TB grant: January to September 2019 Coverage Demonstration phase: 3 districts (Sanghar, Umerkot, Ghotki) in Sindh province (one of the 4 provinces in Pakistan) Scale-up under Global Fund TB grant: 2 districts (Sanghar and Umerkot) in Sindh province Total number of people screened for TB Demonstration phase: 544 717 people were screened by LHWs Scale-up under Global Fund TB grant: 991 128 people were screened by LHWs and 4383 people were screened through mobile camps in Sanghar and Umerkot districts.1 Contribution to TB notification 25% contribution to all TB notifications in selected facilities (1165 people with TB referred by LHWs/4626 people with TB registered in same facilities) Implementers Mercy Corps Pakistan Lions Youth Council (PLYC) 44 300 people (21 people per 100 000 population) died from 1. Introduction the disease in 2018 (1). Improving case detection, treatment Pakistan is one of the eight countries that account for two coverage and adherence is therefore a public health priority thirds of the global tuberculosis (TB) burden. The country in Pakistan, especially in rural communities where case accounts for 6% of the total number of TB cases globally. detection is particularly low. Of an estimated 562 000 people (265 cases per 100 000 population) who fell ill with TB in Pakistan in 2018, 28 000 To respond to these challenges, Mercy Corps implemented people (5%) were infected with multidrug- and rifampicin- the Train, Empower and Mobilize Communities to End TB resistant (MDR/RR) TB (1). Yet, according to the latest WHO (TEAM) initiative from April 2017 to October 2018, funded Global TB Report, only 369 548 persons with TB were through TB REACH, aiming at finding missing persons with reported, leaving 192 452 people with TB unreached by TB through community-based screening by “lady health current services and systems, i.e. over one third (36%) of all workers” (LHWs) in three rural districts of Sindh province, TB cases. Pakistan is also one of the 10 countries that account namely Sanghar, Umerkot and Ghotki districts. Mercy for 75% of the global gap between treatment enrolments Corps was the implementer in Umerkot and Sanghar. The and the estimated number of new cases of MDR/RR TB in 2018 Pakistan Lions Youth Council (PLYC), a nongovernmental (1). According to the latest WHO estimates, approximately organization involved in community development, health, ENGAGE-TB Empowering communities to End TB 1 Chest camps are organized in 19 districts under the Global Fund grant. A total of 41 630 people were screened between January and September 2019. 2 PAKISTAN CASE STUDY human rights and education, was the implementer in the being prioritized (3). As a result, the contribution of LHWs third district, Ghotki. This intervention was later scaled up to TB notification has historically been low. Given the size in two of these districts, Sanghar and Umerkot, through of the TB epidemic in Pakistan, and the large number of the 2018–2020 grant from the Global Fund to Fight AIDS, people left without diagnosis and treatment in the poorest Tuberculosis and Malaria (Global Fund) and was ongoing communities, there was a need to find strategies to harness at the time of writing. This case study covers the activities the full potential of LHWs to increase community-based TB until September 2019. notification and bring services closer to affected individuals and households. Finally, the three target districts in the demonstration phase of this case study in Sindh province In 1994, the Ministry of Health of Pakistan implemented are rural areas where communities lack access to TB the Lady Health Worker Programme as part of a services, owing to various factors including stigma, a lack national strategy to reduce poverty and improve of decision-making power among women and the long health by bringing health services to the doorstep in distances between communities and health facilities. underserved communities. Each LHW is associated with a Government health-care facility, where she receives training, a stipend and medical supplies. LHWs are trained for 15 months in the prevention and treatment of common illnesses. The first three months are spent in the classroom and the remaining 12 months are mostly on-the-job training. To be eligible to enter the LHW training programme, women must have a recommendation from the community, at least eight years of education, a middle-school pass and local residency, and must preferably be married and be at least 18 years of age. LHWs visit households to increase awareness of reproductive health and nutrition, facilitate registration of births and deaths, distribute medication for family planning and immunize children according to the national schedule. LHWs provide regular treatment for diarrhoea, malaria, acute respiratory tract infections and intestinal worms, and offer contraceptives as part of family planning. Each Verbal TB screening session during visit by a lady LHW is affiliated with either a rural health centre or health worker to a household in Umerkot district (Photo: Mercy Corps) a basic health unit, where she is trained and to which she refers her clients. In a rural health centre or basic health unit, clients of LHWs can receive basic health- care services. For more complicated conditions, LHWs are trained to refer patients to nearby clinics. Though there were initial concerns that communities would 3. Proposed solutions not accept LHWs, they have successfully established themselves as important liaison persons within the Mercy Corps piloted the TEAM initiative to encourage primary health care system. LHWs to engage with TB and increase their contribution to the national TB response. In collaboration with the Source: Zhu N, Allen E, Atun R. Lady health workers provincial TB control programme, the LHW programme, in Pakistan: improving access to health care for rural the Department of Health and the implementing partner women and families. 2014 (https://www.researchgate.net/ (PLYC), Mercy Corps provided LHWs with a one-day training publication/332171829, accessed 28 June 2020). course on active TB case-finding techniques through verbal screening and use of the existing referral mechanism during their routine household visits. The training also focused on the importance of TB treatment adherence and follow-up with TB patients. A total of 806 LHWs were trained during the TEAM initiative, and 957 LHWs have been trained so far 2. Description of the problem under the current Global Fund grant 2018–2020. “Lady health The Government of Pakistan created the post of LHW in supervisors” (LHS) were also trained by Mercy Corps and 1994 to address growing inequalities between urban and PLYC to provide monthly supportive supervision for LHWs. rural areas in accessing health care (2). By 2005, about Finally, Mercy Corps and PLYC recruited and trained seven 100 000 LHWs had been recruited and trained to provide community mobilizers and three field supervisors under essential community-based primary health care services the TEAM phase and six community mobilizers and two in urban slum and rural areas.1 However, despite TB being field supervisors under the Global Fund implementation. part of the LHWs’ training and job description, operational They are employees of Mercy Corps and PLYC and receive research revealed that there was a general tendency to monthly salaries; they work closely with LHWs and LHSs, focus on poliomyelitis (polio), immunizations, family conduct regular visits to private and public health facilities planning and mother and child health, and that TB was not and laboratories involved with the project and maintain a 1 Services include support for maternal and child health services, such as family planning including contraception, HIV/AIDS activities and treatment of minor illnesses; health education and promotion of healthy behaviour; antenatal and ENGAGE-TB Empowering communities to End TB postnatal care and referral service for mothers; and basic curative care, including essential drugs for treatment of diarrhoea, malaria, acute respiratory tract infections, intestinal worms, etc. The LHWs are trained to identify and refer more serious cases. PAKISTAN CASE STUDY 3 separate register of people diagnosed with TB who were Community-based awareness-raising sessions referred by LHWs. Community mobilizers also regularly LHWs organize awareness-raising sessions with both men follow up with people with TB, either by phone or in and women in separate meetings (village health committee person, to ensure treatment adherence. and community support group meetings, respectively). The sessions address TB prevention, treatment and care Door-to-door active case-finding issues alongside other health-related topics, such as family During their daily routine visits to five or six households, planning and mother and child health. Harnessing existing LHWs conduct verbal screening of all available household community decision-making bodies has proved essential to members using a simple tool, as well as contact screening foster community ownership and participation. of index cases using a contact screening form. The routine visits also provide LHWs with an opportunity to conduct Incentives for LHWs individual counselling sessions. People with presumptive For each person with TB who is registered,