Pakistan’s primary health care (PHC) services are made up of a relatively large infrastructure of facilities including Maternal and Child Health Centers, Family Welfare Centers, Basic Health Units and Rural Health Centers), assisted by nearly 100,000 community-based Lady Health Workers (LHWs). 

While the facility based Primary Care has a certain potential of improvement, the services provided by the nearly 100.000 Lady Health Workers make up for many of the shortcomings. The Ministry of Health’s National Program for Family Planning and Primary Health Care, commonly referred to as the Lady Health Workers (LHW) Program, was launched under the Eighth Five Year Plan in 1993, aimed at increasing access to basic preventive health care services, particularly in rural areas. Lady Health Workers (LHWs) deliver a range of services related to maternal and child health including: promoting childhood immunization, growth monitoring, family planning and health promotion. They treat minor ailments and injuries, and are trained to identify and refer serious cases. Their family planning responsibilities include motivating women to practice contraception, providing pills and condoms, and referring consenting cases for injections, IUDs and/or sterilization. They are provided with a kit that includes contraceptive pills, condoms, paracetamol syrup and tablets, eye ointment, ORS sachets for diarrhea, chloroquin for malaria and cotrimoxazole for respiratory infections. A referral form is used to refer patients requiring further care to the next level facilities. 

Lady Health Workers

LHWs have a minimum of eight years of education and permanently reside in the community that they serve. They are attached to a government health facility, from which they receive training and medical supplies. After undergoing three 3 months full time training, followed by 12 months of in-service training, they serve around 1000 individuals which comprise of about 150 households in their catchment area. They receive a small allowance and are supervised by LHW Supervisors. They are presently covering about 55% of total population of Pakistan, close to 65% of which resides in the rural areas.

Prior to the launching of the LHW program, Pakistan had one of the highest levels of unmet need for family planning services in the world1. Contraceptive use has, however, more than doubled, from 11.9% in 1990-912 to 27.6% in 2000-013, bringing about a decline in the fertility rate4. The increase in contraceptive prevalence rate (CPR) has been increasing over the last few years, albeit very slowly, with the figure just touching 30% in 20065. Currently, the CPR in areas covered by LHWs is more than 40% as compared to the national figure of 30%, highlighting the contribution made by these community-based workers. As the national average also includes LHW served areas thus in fact the actual difference between covered and uncovered areas is in fact substantially higher than 10%.

The data has been substantiated by several independent sources. A recent national survey concluded that married women living within 5 kms of community-based workers were significantly more likely to use a modern, reversible method than were women who had no access. Another evaluation was conducted six years after the program was launched was largely handicapped due to the lack of baseline data. Measures of impact in this evaluation were estimated from a comparison between the population served by the LHWs and a control population selected for the study. LHWs who had worked in their community for a minimum of 4 years were eligible for inclusion in the sample, so that their impact on outcome measures in the population served by them could be better evaluated. 

The data suggests that the higher level of contraceptive use seen in rural LHW areas has occurred after the introduction of the LHWs, and is consistent with the hypothesis that LHWs have played a role in increasing contraceptive use in the population that they serve. It is pertinent to note that LHW areas are more advantaged than control areas on a number of socioeconomic indicators, and this might have had an impact on the uptake of modern reversible methods in these areas. However, results from the logistic regression analysis show that even after controlling for other factors, use of reversible modern methods was higher in areas served by LHWs as compared to the control areas. The net effect of the LHW Program on the use of reversible modern methods was substantial and significant.

The role of LHWs in improving the Skilled Birth Attendance (SBA) rate is also laudable. The LHWs job description includes getting the mother prepared for birth and facilitating her to involve SBA at the time of delivery. The national average for skilled birth attendant assisted deliveries in 2006 was 39%5 whereas it has remained consistently higher in areas covered by LHWs being 50% during the first half of 2007. Similar trends are also discernable for TT coverage of pregnant women and antenatal care.

Another important area of work for the LHW Program is child and neonatal health, as around 10 million children are estimated to die before the age of five8, although a large proportion of  these deaths can be avoided through preventive measures and early low cost treatment of these sick children at home or in the community with antibiotics, anti-malarials and oral rehydration therapy. The program is addressed this aspect through provision of training, logistics and referral linkages in the community, while using WHO case management guidelines to classify pneumonia and treat fever presumptively with the help of charts and the provided kits. Evidence suggests that the ability of LHWs to manage multiple diseases is generally adequate although there are some deficiencies, which may vary according to disease and severity10. The most common diseases encountered by LHWs in children under-5 are diarrhea, respiratory tract infections and fever with an average of 17 cases per month for the year 2006. The impact of using this model on IMR was assessed in 2000 during a third party evaluation, which found that measures of child morbidity decreased in covered area although the impact on IMR as compared to other areas was not significant when controlled for other factors11. Currently, the national IMR is 78 as compared to 51 in LHW covered areas12. Another third party evaluation is currently underway to evaluate these positive impacts in greater depth. 

Integrated PHC

At present, several health-related programs are working under national management, to target specific conditions of ill health in Pakistan. Each programme has an independent organizational set-up from the federal, provincial, district to the first level care facilities (FLCF). Underutilization of available human resources and public health facilities due to low quality of health care services and high rate of absenteeism needs to be corrected by improvement in district health management, development of feasible standards and guidelines for service delivery and improvement in quality of care at various levels in the district. Experiences from other regional countries has shown that integrated health services can improve coverage and quality of health services, increase the level of community involvement, provide continuous availability of care, reduce the costs of health delivery, optimize use of scarce resources and prevent duplication of unnecessary services at different levels, improving the accountability within the health system.

Objectives

• To improve the existing capacity of LHWs and their supervisors in provision of quality health care services;

• To develop a model for a referral system at tehsil and district level;

• To improve the public-private partnership in delivery of health care services;

• To improve planning and management capacities of district health care professionals;

• To introduce a system of accreditation in the district health care system;

• To reduce maternal mortality in high-reporting districts;

• To reduce protein-energy malnutrition amongst children under 3 years in 10 high reporting districts.