Tuberculosis (TB) have been declared to be a global public health emergency by the world health organization (WHO) nearly three decades ago in 1993. Human immunodeficiency virus (HIV) and the emergence of multidrug resistant TB (MDR TB) fuelled the pandemic and complicated its prevention and control efforts[1]. ‘END TB’ strategy was developed in 2014 with targets to reduce TB incidence by 50% (to less than 55 TB cases per 100,000 population) and reduce TB deaths by 75% compared with 2015, and no affected families facing catastrophic costs due to tuberculosis by 2025[2]. However, TB was one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent (ranking above HIV/AIDS)[3]. Globally, an estimated 10.0 million people fell ill with TB in 2019 and there were an estimated 1.2 million TB deaths among HIV-negative people, and an additional 208 000 deaths among HIV-positive people during the year. Despite increases in TB notifications, there was a large gap between the number of new cases reported and the estimated incident cases in 2019 as it was the case during previous years. Access to universal health care, including TB, is still falling short of universal health coverage[3].
Africa contributed the second largest percent of TB cases (24%), next to the South-East Asia WHO regions, to the world’s TB cases in 2018. Ethiopia is among the 30 global high TB burden countries and one of the ten triple burdened (TB, TB/HIV and MDR TB) countries in the world[4]. The country adopted WHO strategies and guidelines to combat and reverse the TB transmission [1,5]. TB case notification is neither adequate for WHO estimated incident cases nor consistent across local diversities in the country due to variation in access to TB prevention and control services [6]. Pastoral community is one of the most marginalized settings in the country, particularly in regions where the agrarian community is predominant [7]. But, pastoral communities occupy 43% of the land mass of Africa and Ethiopia is one of 36 countries with large area of the pastoralist livelihood community [8].
Pastoralism is a culture, livelihood system, extensive use of rangelands. It is the key production system practiced in the arid and semi-arid dryland areas. Recent estimates indicate that about 120 million pastoralists and agro-pastoralists life worldwide, of which 41.7% reside only in sub-Saharan Africa[9]. Pastoralists live in areas often described as marginal, remote, conflict prone, food insecure and associated with high levels of vulnerability. Pastoral communities of Ethiopia occupy 61% of the total land mass and 97% of Ethiopian pastoralists found in lowland areas of Afar, Somali, Oromiya, and SNNPR. In spite pastoral areas have a significant role in the national economy, yet very little consideration was given to pastoral development and policy makers often neglect them, focusing on the interests of agriculture and urban people[7].
The health system of Ethiopia was highly centralized and access to basic health services was very poor since 2003. Among other efforts to improve the access, the country has been implementing a community health extension program (HEP) since the year 2003 where community health workers, called health extension workers provide packages of primary health care activities at community level [10,11]. Implementing the program enabled Ethiopia to achieve significant improvements in maternal and child health, communicable diseases, hygiene and sanitation, knowledge and health care seeking[11,12]. In spite of these successes, the program is currently facing challenges that remain to be addressed. These challenges are related to productivity and efficiency of the community health extension workers (CHWs), working and living conditions of CHWs; capacity of health posts and, other determinants of health[13].
As part of the communicable diseases prevention and control package, TB prevention and control activities have been decentralized to the community level where CHWs provide short course directly observed treatment (DOTs) in health posts, the most peripheral health facility, located in the smallest administrative unit called kebele. Besides the DOTs service provided in this health facility, CHWs are responsible for presumptive TB case identification and referral, provision of health education and adherence support among other activities by conducting regular home visits. The CHWs, the health extension workers, are female and most of them have families including young children. In the pastoral community setting where community settlement is highly scattered and where access to transportation facilities for the CHWs is either limited or unaffordable, it is difficult to imagine how targets set for the TB prevention and control is to be met.
Therefore, in the pastoral community setting, where CHWs are engaged in the prevention and control of TB, including identifying presumptive TB cases and referring them to health facilities for diagnosis along with other primary health care services, exploring the program to understand the performance in terms of case identification and DOTs services provision, assessing factors underlying the performance and pointing out solutions from the perspectives of the implements (CHWs) is important.