Aga Khan Health Service, Pakistan (AKHS, P) aspires to see a world with healthy population and without health inequity. It wants people to have access to affordable and functional health services during sickness. Mental illness is an underdiagnosed and undertreated health problem in poor countries and poor populations. The involvement of community health workers has the potential to address mental health problems in a feasible and appropriate manner, especially in disadvantaged and isolated communities.

Problem

Aga Khan Health Service, Pakistan (AKHS, P) aspires to see a world with healthy population and without health inequity. It wants people to have access to affordable and functional health services during sickness. Mental illness is an underdiagnosed and undertreated health problem in poor countries and poor populations. The involvement of community health workers has the potential to address mental health problems in a feasible and appropriate manner, especially in disadvantaged and isolated communities.

Solution

Diagnosis and management of mental illness is considered reliable if provided by mental health care specialists who are generally available only in the urban setting. Women and young girls in remote communities are more at risk of developing mental illness because of socio-environmental risk factors such as restricted mobility, patriarchal society and lack of women empowerment. However, stigma attached to the mental illness and high cost of care in urban centers poses major barriers in their timely seeking of care. Community believes in supernatural causes to these symptoms hence local healers are preferred providers for mental illnesses. These providers use harsh treatment such as burning body parts, thrashing the patient, restraining them in chains etc. AKHS, P Maternal and child health clinics are present in each of these areas and are accepted women friendly spaces. LHVs are respected and trusted care providers for MCH and primary care. Therefore, AKHS, P decided to broaden the role of LHVs in early diagnosis, follow up care and counseling of patients with mental illness. Visiting doctors and LHVs of AKHS, P was trained in AKHS, P designed protocols, identification, classification and management of mental illness. Diagnosis made by LHVs was then corroborated by trained visiting physicians. The innovation has opened doors for provision of care for mental illnesses in the rural areas which are otherwise hard to reach.

Example

To provide access to mental health services particularly to women in the rural areas, the Aga Khan Health Service, Pakistan and a team of international collaborators piloted a model of basic mental health care delivery through LHVs who are the only certified health care providers in these areas. The pilot has two aims: 1) Train LHVs in diagnosis, basic mental health counseling and follow up care; 2) Launch mental health destigmatization campaign in selected regions. Diagnostic and depression management guidelines were developed in collaboration with the Aga Khan University, WHO and psychologists from Yale and Tehran University for use as a reference guide by the LHVs. The study was launched in the four remote valleys of Chitral district: Chuinj, Gharam Chashma, Herchine and Susoom. Training of LHVs and the destigmatization campaign were launched between April and September 2010 in different areas. After participating in destigmatization and awareness programs, community brought their family members to LHVs who used diagnostic criteria and protocol to confirm their diagnosis. Their diagnosis is corroborated by the visiting physician who visits the area once a month.

Marketplace

Four areas selected for the project include Chuinj, Gharamhashma, Susoom and Herchine in Chitral district of Khyber-Pakhtoonkhwa, Pakistan with a total population of around 35000. The main source of income in these areas is considered to be subsistence agriculture with average land holding of less than one hectare; 90% of the population is engaged in farming. A household income and expenditure survey conducted by the Aga Khan Rural Support Programme (AKRSP) in Northern Areas and Chitral in 1991 revealed that 75% household income was being derived through off-farm sources in Chitral. The socioeconomic status of the majority of the population is very low in these areas as compared to other villages in the district. According to socio- economic survey conducted by AKRSP in 2005, 41% of the population of the district live below the poverty line and an additional 16% qualify as ‘vulnerable’ or in danger of falling under the poverty line. According to 1998 census report, the literacy rate of the district was 40%. The literacy ratio in female was 22% while male literacy rate was 58%. Though the ethnic region of Chitralis (inhabitants of Chitral) is associated with central Asia's cultures but being part of the Khyber Pakhtunkhwa province of Pakistan, the Chitrali society is highly influenced by the neighboring Pathan / Pushtun and Afghan customs and traditions, resulting in conservatively restricted participation and mobility of women folk in the mainstream activities of socio-economic development. In the recent decades, there has been an increasing trend of providing early age education to girls but in fact, higher education for females is still not being taken seriously, which results in lack of leadership among the local women in Chitral. As a tradition, women are considering to be responsible for household chores, taking care of children and livestock and participating in farming activities with their male counterparts.