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Mercy Corps is a non-profit international non-governmental organization, which has been operational in Pakistan since 1986. Since then, Mercy Corps’ activities have expanded throughout the country. Mercy Corps is improving livelihood, increasing access to health care and helping communities recover from emergencies. These initiatives are revitalizing communities and helping people live healthier and more productive lives. Mercy Corps has been the principal recipient of The Global Fund to fight AIDS, TB and Malaria grants for TB Control activities in the private sector since 2007. The Global Fund has been the largest donor to Pakistan in bridging the gap for TB funding in the country. Mercy Corps is working in close coordination and collaboration with National and Provincial TB Control Programs, contributing to the overall national case notification of TB cases. Mercy Corps has also been working closely with LHWs program since 2004 in Sindh and Baluchistan. Currently, Mercy Corps is implementing the Health Communications Component of the USAID’s Maternal and Child Health (MCH) program in ten districts of Sindh in which Mercy Corps is supporting LHWs in effectively conducting the Community Support Group meetings (CSGs). So far, Mercy Corps has built the capacity of more than 6,000 LHWs on the use of interpersonal communication toolkit during CSGs and household visits.
Pakistan has the fifth highest Tuberculosis (TB) burden amongst the 30 high burden countries of the world. Each year more than half a million people develop TB in the country; of these more than 50 percent are bacteriologically positive. The incidence rate is 270 per 100,000, whereas the prevalence rate is 341 per 100,000. The overall TB mortality rate is 23 per 100,000. During 2015, around 331,000 TB cases were diagnosed and put on anti-TB treatment leaving about 198,000 (34 percent of estimated cases) patients undiagnosed and untreated. This huge pool of undetected or “missing” TB cases is a cause of great concern for the national and provincial TB control programs and international partners. It is highly likely that these active, incident TB cases are neither properly diagnosed nor receive quality care outside of national and provincial TB control programs. Furthermore, these cases will often face a long delay before they are eventually diagnosed. Till the time, they remained un-diagnosed one TB patient can infect 10-15 healthy individuals in a year. It is expected that the majority of the missing cases seek healthcare in the private sector. Further, a high proportion of missing TB cases in Pakistan resides in the rural areas. The National TB Control Program’s (NTP) prevalence survey of 2011 showed that the prevalence of TB was higher in rural than in urban areas, and was higher in men. A number of factors lead to delays in diagnosis; these include low knowledge of the signs and symptoms of TB, lack of awareness about TB services, and poor diagnosis. The TB response in Pakistan remains focused on quality of diagnosis and care, with little emphasis on community engagement. Similarly, the strategies to find the ‘missing cases’ remain focused on urban and peri-urban areas, with practically no innovative solutions to find and register cases from rural areas. Several studies have demonstrated the effectiveness of the role of community health workers (CHWs) in improving health indicators and in TB case identification, contact tracing, and treatment support in particular. For example, case notification increased substantially with the help of health extension workers in rural Ethiopia. Similarly, CHWs have played a successful role in active case finding in Brazil, in improving treatment success rates in South Africa , and in contact tracing in Spain . In Pakistan, Lady Health Workers (LHWs) are the frontline CHWs with deep reach, especially in rural populations. Each LHW covers a population of 1,000-1,500 through Community Support Groups (CSGs), Village Health Committees (VHCs) and household visits. The LHWs have been successfully employed in contact tracing and other active case finding initiatives on a small scale, but their potential to systematically increase TB case notification has not yet been tapped. Mercy Corps through TEAM to End TB project proposes to enhance the capacity of LHWs in contributing towards TB control in selected districts of Sindh.
Under the TEAM to End TB project, Mercy Corps aims to “increase case notification through suspect identification and referrals by LHWs in rural Sindh” (Overall Objective). This will be achieved through the following strategies:
Strategy 1: Engagement with the Sindh LHW Program and Provincial TB Control Program (PTP) for review and improvement of policies and practices related to LHWs role in TB control. This will address coordination, commitment and agreement on operational modalities including a referral mechanism, future scale up and sustainability of the project. Key activities include: 1) establishment of a provincial inter-program coordination committee (PIPC) meeting on a quarterly basis, 2) a consultative workshop (as part of PIPC) at program onset to develop and build consensus on operational guidelines, and 3) a dissemination workshop at project completion.
Strategy 2: Capacity building of LHWs and Village Health Committee (VHC) members on TB. Mercy Corps (in partnership with the PTP and LHW Programs) will develop training guidelines and job aids for LHWs including a verbal screening tool and will provide a one-day TB training to LHWs, Lady Health Supervisors (LHS) and key members of the VHCs. Mercy Corps and its partner, Pakistan Lions Youth Council (PLYC), will conduct monitoring and supervision through weekly and monthly meetings and spot checks.
Strategy 3: Presumptive/suspect identification and referral. As the main intervention in the proposed project, LHWs will be supported to screen and identify presumptive cases and refer them for diagnosis and care using their existing core tasks i.e. CSGs, VHCs and household visits. CSGs and VHCs will be used to disseminate messages about TB and raise awareness, as well as to identify households that need follow up visits. During household visits, LHWs will implement a verbal screening tool developed under the proposed project for presumptive identification. The LHWs will have a list of participating Basic Management Units (BMUs) and General Practitioners (GPs) as well as referral slips to refer presumptive cases for diagnosis. LHWs will receive an incentive against registered cases. Where needed, Mercy Corps and its implementing partner will organize periodic chest camps to conduct sputum smear microscopy of presumptive cases identified by LHWs.
Jointly with the Sindh LHW Program and PTP, and with PLYC as an implementing partner, Mercy Corps is implementing this project in seven rural talukas (sub-district level) of three districts (Sanghar, Umerkot and Ghotki) in Sindh. According to NTPs’ prevalence data, at least two of these seven Talukas have a prevalence higher than 500 per 100,000 population. In the remaining five, the prevalence is likely to be higher than the national average. There are a total of 14 public sector BMUs and 38 private sector reporting GPs with a total catchment population of 2.3 million.
Mercy Corps will engage 802 LHWs that cover a population of 814,939 (target population) in these Talukas. The details of Taluka’s is given below: