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"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.

By: 
Rose Zulliger

Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.

Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time.


Summary
Background

The Lady Health Worker Program (LHWP) was established in 1994, with the goal of providing primary care services to underserved populations in rural and urban areas. In 2003, the national strategic plan set two goals: (1) improving quality of services and (2) expanding coverage of the LHWP through the deployment of 100,000 Lady Health Workers (LHWs) by 2005.

Implementation

LHWs are deployed throughout all five provincesq of Pakistan. These workers are attached to a local health facility, but they are primarily community based, working from their homes.

Training

LHWs are trained in classrooms for 3 months and then have 1 year of on-the-job training. This should include 1 week of training per month for a period of 12 months as well as 15 days of refresher training each year, although there is substantial variation in training patterns across provinces.

Roles/responsibilities

The scope of services provided by LHWs has grown from an initial focus on MCH to include participation in large health campaigns, newborn care, community management of TB, and health education on HIV/AIDS. LHWs visit an average of 27 households a week, providing advice and conducting consultations with an average of 22 individuals each week.

Incentives

LHWs receive a salary of about $343 per year. They are not supposed to engage in any other paid activity, although some do. The LHW stipend is often the only source of family income and is a critical family support.

Supervision

Supervision is highly organized and tiered in the Pakistani LHWP. LHWs are each attached to a public health clinic and are supervised on a monthly basis by an LHW Supervisor (LHS). LHWs should have community-based supervision at least once a month in which LHSs meet with clients and with the LHWs, review the LHWs’ work, and make a work plan for the next month.

Impact

Pakistan is lagging behind in its efforts to achieve the MDGs for MCH. Although the LHW Program has many positive aspects, the number of LHWs is still not sufficient to provide adequate coverage of services nationally. Thus, expansion of the program and continued efforts at program strengthening will be required to achieve a stronger impact.

What is the historical context of Pakistan’s Community Health Worker Program?

Pakistan’s support for PHC dates back to the country’s signing of the 1978 Alma Ata Declaration.1 In 1993, Pakistan established the Prime Minister’s Program for Family Planning and Primary Health Care, which employed CHWs to provide PHC services in their communities. The program subsequently employed only female CHWs, and the LHWP was introduced in 1994.2 The goal of the program was to reach rural areas and urban slums with a set of essential PHC services, including promotive, preventive, and curative services; to improve patient-provider interactions; to facilitate timely access to services; to increase contraceptive uptake; and, ultimately, to reduce poverty.1,3,4 In 2000, the program was renamed the National Program for Family Planning and Primary Health Care, but it is still commonly called the Lady Health Worker Program (LHWP).5

The 2003–2011 Strategic Plan set two goals: (1) improving quality of services and (2) expanding coverage of the LHWP through the deployment of 100,000 LHWs by 2005. Key determinants of provision of high-quality service by LHWs include the following: selection based on merit; provision of professional knowledge and skills; supply with necessary medicines and other supplies; and adequate remuneration, performance management, and supervision. A management information system was also essential to assess and encourage quality performance and to facilitate informed programmatic decision-making.6 The 2001–2011 National Health Policy described “investment in the health sector as a cornerstone of the government’s poverty reduction plan.”3

The LHWP has evolved over time. The scope of services provided by LHWs has grown from an initial focus on MCH to now include participation in large health campaigns, newborn care, community management of TB, and health education on HIV/AIDS. LHWP activities have also been advertised in a series of mass media campaigns that promote community uptake of and respect for LHW services.7

What are Pakistan’s health needs?

MCH indicators in Pakistan have lagged behind the same indicators in other South Asian countries. In 1991, the under-5 mortality rate was 117 deaths per 1,000 live births and the MMR was 533 maternal deaths per 100,000 live births.8 Since then, Pakistan has made insufficient progress toward meeting MDG 4 (reducing under-5 mortality). The average annual rate of reduction from 1990 to 2010 was only 1.8% and there were 87 under-5 deaths per 1,000 live births in 2010. Pakistan is, however, making progress in meeting MDG 5 (for reducing maternal mortality) and the MMR has had an annual reduction of 3% from 1990 to 2010. In 2010, the MMR was 260 deaths per 100,000 live births.9 Part of the high maternal mortality earlier was attributable to the high total fertility rate (5.4 children in 1991) and low access to health services; only 15% of women reported at least one ANC visit during their most recent pregnancy.8 (The total fertility rate measures the average number of children a woman would have if she lived through her entire reproductive life at the age-specific rates of fertility in her country.) Health care access in Pakistan is further restricted by social and cultural barriers such as women’s limited mobility outside of the home without an escort.10

What is the existing health infrastructure?

There are three tiers of governance in the Pakistani public health system: federal, provincial, and district. The federal government historically was responsible for broader policies, planning, and budgeting as well as the HMIS. However, in 2011, the FMOH was dissolved and responsibility for health services was delegated to provinces, with the exception of a national Ministry of Regulation.11

Provinces are responsible for LHW allotment, training, and performance. The district level is responsible for allocation and supervision of LHWs.4,6 All tiers of government are involved in the LHWP and LHWs are integral to service delivery of most community health initiatives in the country.8

There has been tremendous growth in the number of health care providers in Pakistan. For example, the number of physicians increased from 70,692 in 1995 to 127,859 in 2007, according to data from the Pakistan Medical and Dental Council and Pakistan Nursing Council.3 There is also a private health care system in Pakistan that provides services for wealthier inhabitants.5

What type of program has been implemented?

LHWs are deployed across the nation in all five provinces of Pakistan.12 These workers are attached to a local health facility, but they are primarily community based, working from their homes.3 The homes of LHWs are called Health Houses; emergency treatment and care are provided therein.1 An LHW is responsible for approximately 1,000 people, with priority given to couples of reproductive age and children younger than 5 years.

An external evaluation of the LHWP was carried out in 2008 and reported the following in 2009:

  • LHWs visit an average of 27 households a week.
  • LHWs provide advice and conduct consultations with an average of 22 individuals each week.
  • 85% of households reported that they were visited by an LHW in the previous 3 months.
  • 80% of LHWs reported that they worked 6–7 days a week.
  • Most LHWs worked an average of 5 hours a day.2

The LHWP offers professional advancement opportunities for LHWs. LHWs can receive additional training to serve as an LHS, which is an incentive for good performance.5

LHWs have a broad scope of work that includes 22 different tasks.1 These include promotion of use of contraceptives, provision of FP services (distribution of oral contraceptives and condoms and provision of injectable contraceptives), ANC (alongside traditional and formal medical birth attendants), treatment of illnesses (such as diarrhea, malaria, acute respiratory tract infection, and intestinal worms), and referral of community members with more serious illnesses.3,4,8,10 In addition, LHWs are expected to provide DOT for TB patients, carry out surveillance for cases of polio, and keep comprehensive records for all of their patients.1

The most frequent LHW services, as reported by the 2008 survey of clients, were hygiene promotion, vaccination promotion, and FP services.2 Seventeen percent of households reported that they consulted with an LHW for curative services.2 LHWs also frequently support other health campaigns such as polio campaigns.8

A 2000 evaluation estimated that 150,000 LHWs were needed to obtain optimal coverage in the country.3 This led to a strategic plan in 2003 to have 100,000 functioning LHWs by 2005. This goal was still not achieved by 2008. In 2003, there were a total of 75,038 LHWs working or in training and the number grew to 83,280 in 2005 and 90,074 in 2008.6

The expansion of the program from 2000 to 2008 increased LHW coverage in more rural and poorer areas, but the program still does not reach the most disadvantaged areas. Coverage rates have, however, improved.2 In 2006, the LHWP covered 60% to 70% of Pakistanis in rural areas.4 There are now plans to double the number of LHWs.8

What about the local community’s role?

There is a community member on each LHW selection committee and on each LHS selection committee. The community is also involved in programmatic decision-making, planning, and M&E. LHWs are expected to link the community to formal health services and to be members of the community where they work. LHWs also provide a range of community development services and participate in community meetings.5 LHWs are expected to establish a village health committee, which has two parts—a women’s health committee and a men’s health committee.

How does Pakistan select, train, and retain Lady Health Workers?

LHWs are women who have a minimum of 8 years of education. This requirement has been a challenge in some areas where there are no or few women with this level of education.8 They also must be between 18 and 50 years old; reside in, be accepted by, and be recommended by the communities they serve; and preferably be married with children. LHWs must also be willing to work from their homes. Preference is given to women who have experience in community development.6 Of LHWs included in a 2008 external evaluation of the program, 66% were younger than 35 years of age, 97% resided in the community where they worked, 66% were currently married, and the average education level was 9.9 years of schooling.2

LHWs are selected using a clearly delineated process. LHW posts are advertised; applicants are then interviewed and selected based on the above criteria by a selection committee. The committee is expected to comprise the following members: a Medical-Officer-In-Charge who is the chairman, a female Medical Officer, a Lady Health Visitor (female medical technician), a Dispenser (male health technician), and a community member. They also must be recommended by the councilor, who is a local elected official, and provide a written affidavit that they will perform their duties for at least 1 year after the completion of their training.12 The selected LHW is then formally appointed by the District Health Officer.6 LHWs are then initially employed for 1 year, although many continue the work long after the first year.5

LHWs receive 3 months of classroom training in PHC and then have 1 year of on-the-job training. This should include 1 week of training per month for a period of 12 months, followed by 15 days of refresher training each year, although there is substantial variation in training patterns across provinces.1,2,6 The Federal Project Implementation Unit is responsible for approval of all LHW training and, with the FMOH, develops the training curriculum, organizes and coordinates training, and trains master trainers; Provincial and District Project Implementation Units are responsible for the local trainings.6

The fourth external programmatic review reported in 2009 that 100% of the LHWs had attended the initial training and 96% had some kind of refresher training in 2008. Eighty percent of LHWs had attended training on child health in the previous year. Seventy-two percent had obtained training on counseling cards, 70% on optimal birth spacing intervals, and 62% on injectable contraceptives during 2008. Eighty-eight percent reported receiving training by male medical doctors and 67% reported receiving training by Lady Health Visitors. Eighty- two percent of LHWs had at least one female trainer.2

Recently, training has focused more on counseling skills and competency, although challenges persist. LHW knowledge increased between the third and fourth external programmatic evaluations, but according to the findings of the 2008 survey, there were very low levels of knowledge on certain subjects. For example, only 9% of LHWs stated the correct dosage of chloroquine for children despite having access to manuals and medicine boxes, and only 50% could determine the appropriate weight of a child from a standard-growth monitoring card.2 Additionally, some LHWs felt they had insufficient communication skills, particularly for addressing difficult topics such as communication with men on FP, establishment of village health committees, and discussion of sexually transmitted infections. These LHWs felt they needed additional training through role plays as well as additional information, education, and communication materials.7

LHWs receive a salary of about $343 per year and are not supposed to engage in any other paid activity, although some do.3 The LHW stipend is often the only source of family income and is a critical family support.8 Salaries are paid monthly into the LHWs’ personal bank accounts, but delays in LHW remuneration are common. Additionally, 9% of patients reported that they paid their LHW for services, which are supposed to be free.2

How are Lady Health Workers supervised?

Supervision is highly organized and tiered in the Pakistani LHWP. LHWs are each attached to a public health clinic and are supervised on a monthly basis by an LHS.3 LHSs are then regularly supervised by the LHWP district coordinator and assistant coordinator. LHWs should have supervision take place in the community at least once a month, at which time LHSs meet with clients and with the LHWs, review the LHWs’ work, and make a work plan for the next month.2

The evaluation of the LHWP found that 80% of LHWs had had a supervision meeting in the previous month. Ninety percent of supervision occurred in the village, and in 59% of the cases, the supervisor met with clients of the LHW. Ninety-one percent of LHWs also reported that they had had meetings in the health facility within the previous 30 days, and 98% reported that they had produced a work plan for the previous month. Supervisors frequently used checklists during the meetings and scored LHW performance, although often LHWs were not told their score.2

This same evaluation also assessed the characteristics and knowledge of the LHSs. LHSs are required to have passed 12th grade, but 66% had achieved a higher level by completely graduating or even obtaining some postgraduate education. The LHSs are, on average, 32.5 years old; 69% are currently married. LHSs receive 3 months of full-time basic training at the District Health Office, followed by 1 week per month of classes for the next 9 months. According to the evaluation, 100% of LHSs had attended the 3-month training and 79% had received at least some additional training. They generally had high levels of knowledge, although on a few subjects, their level of knowledge was quite low. LHSs were each responsible for 23 LHWs on average. Sixty percent had full-time access to a vehicle, although not all receive their petrol, oil, and lubricants allowance.2

LHW performance is monitored by provincial and district coordinators, and the LHWP also has its own monitoring system.3 The Monitoring Information System is the monitoring system implemented by the LHWP using standardized monthly reports.6 LHWs keep comprehensive health records on their community and track individual care and community health indicators.1 This information is consolidated in monthly reports, and data are presented by managers and inspectors at regular meetings held at all levels to assess programmatic performance and to facilitate discussion of possible resolutions to identified barriers hindering successful program implementation.6

A 2006 rapid assessment of the monitoring system by the World Bank found that there were substantial issues with the system, including irregular and inappropriate quality checks, inaccuracies in the aggregation of LHW reports, and poor understanding and analysis of the data. The 2008 external review found that key indicators such as annual recruitment of LHWs were not collected, internal inconsistencies in the data persisted, and there was little demand for quality information from program managers. The review did find that progress had been made in monthly reporting.6

How is the Lady Health Worker Program financed?

The Pakistani government is the largest funder of the LHWP, but the program has been underfunded since its inception. The LHWP cost $155 million in its first 8 years (through 2003) and was largely supported by government funding, with only 11% provided by external donors. In 2004, $356.6 million was approved for extension of the program from 2003 to 2008. Overall, the program spent approximately $570 per LHW per year between 2003 and 2008.3

Approximately 70% of LHWP costs are for LHW stipends, drugs, and contraceptives; and additional 4% are for training.6,13 LHW salary costs increased 31% between 2003 and 2008, leading to a reduction in other expenditures, especially for LHW kit supplies.13 Other estimates indicate that the cost per LHW (including her salary, supplies, training, supervision, and administration) is approximately $745 per year (or 75 cents per person served per year).3

What are the program’s demonstrated impact and continuing challenges?

The LHWP has undergone four external evaluations since its inception, most recently in 2008. The 2008 evaluation included a nationally representative survey of 554 LHWs. There was also a survey of 5,752 households with varying levels of exposure to LHWs (ranging from unexposed households to those that had extensive exposure to LHWs) and extensive qualitative interviews with programmatic supervisors and managers, medical staff, and community groups. The evaluation found that overall LHW performance, defined as the percentage of households who received services from LHWs, improved between 2000 and 2008. Coverage was similar in rural and urban areas. Higher LHW performance was associated with longer LHW experience, increased hours worked in the previous week, and LHW reports indicating that LHWs had a higher level of autonomy in the home, attendance at training, regular meetings with supervisors, and work in communities with Women’s Health Committees, among other factors.2 Ninety percent of community members surveyed indicated that there were health improvements associated with the LHWs’ work.6

The 2008 evaluation assessed improvements in health indicators and found improvements in tetanus toxoid coverage, percentage of deliveries attended, percentage of children fully immunized, awareness in mothers of how to prepare ORS, and levels of exclusive breastfeeding. There were, however, some negative trends from 2000 to 2008, such as decreases in maternal knowledge of how to prevent diarrhea and a persistently low prevalence (less than 10%) of certain important health-related behaviors such as purifying water prior to drinking it.2

The LHWP is highly accepted, and the LHWs have proven adept at taking on additional tasks.1 The population served by LHWs had substantially better health than the population without LHWs, including an 11% increased likelihood of using modern FP and a 15% increase in immunization coverage among children younger than 3 years of age. The effect of LHW services was generally greatest in poorer households. The program has, however, had little impact on skilled attendance at delivery, growth monitoring, and incidence of diarrhea and respiratory infections in children.2

The effect of LHW services has also been demonstrated in smaller, intervention studies. In 2008, Bhutta and colleagues assessed the feasibility of a package of perinatal health care interventions delivered by LHWs and TBAs.14 The researchers found that the villages where LHWs and TBAs were linked and received a brief training on newborn care and service delivery had significant reductions in the number of stillbirths and in the neonatal mortality rate. A different study of the impact of the LHWP on contraceptive use found that women in LHW service areas were 50% more likely to use modern reversible contraceptives than those who did not receive LHW services.10

Some of the challenges facing the Pakistan LHWP are underfunding and insufficient coverage, with up to 40% of eligible families still not being served by an LHW.3 Other challenges include low-quality LHW training, poor supervision, inadequate supply systems (especially for drugs and contraceptives), and lack of timely payment of salary. Broader health system challenges include shortages and misdistribution of human resources for health (HRH), weak management, absence of quality-control systems, and a lack of coordination across HRH stakeholders.11

There has also been dissatisfaction from LHWs, leading to increased organization of LHWs and demands for additional formalization and benefits. LHWs also have become resistant to participating in intermittent campaigns—such as the polio eradication campaigns—because they had become vulnerable to violence; 11 LHWs were abducted and beaten when they were participating in a 2007 vaccination campaign. LHW boycotts of a 2010 campaign led to a subsequent Supreme Court order for a higher salary (7,000 Pakistani rupees each month).8 There are concerns, though, that the expansion in LHWs’ responsibilities has increased their job-related stress.15

References

  1. Hafeez A, Mohamud BK, Shiekh MR, Shah SA, Jooma R. Lady health workers programme in Pakistan: challenges, achievements and the way forward. J Pak Med Assoc. 2011;61(3):210-215.
  2. Oxford Policy Management. Lady Health Worker Programme: External Evaluation of the National Programme for Family Planning and Primary Health Care; Quantitative Survey Report. Oxford Policy Management; 2009. Available at: http://www.opml.co.uk/projects/lady- health-worker-programme-third-party-evaluation-performance.
  3. World Health Organization, Global Health Workforce Alliance. Country Case Study: Pakistan's Lady Health Worker Programme. Geneva, Switzerland: World Health Organization and Global Health Workforce Alliance; 2008.
  4. Jalal S. The lady health worker program in Pakistan—a commentary. Eur J Public Health. 2011;21(2):143-144.
  5. Bhutta ZA, Lassi ZS, Pariyo GW, Huicho L. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems. Geneva, Switzerland: WHO and Global Health Workforce Alliance; 2010.
  6. Oxford Policy Management. Lady Health Worker Programme: External Evaluation of the National Programme for Family Planning and Primary Health Care; Systems Review. Oxford Policy Management; 2009. Available at: http://www.opml.co.uk/projects/lady-health- worker-programme-third-party-evaluation-performance.
  7. Haq Z, Hafeez A. Knowledge and communication needs assessment of community health workers in a developing country: a qualitative study. Hum Resour Health. 2009;7:59.
  8. Khan A. Lady health workers and social change in Pakistan. Econ Polit Wkly. 2011;46(30):28-31.
  9. WHO, UNICEF. Building a Future for Women and Children: The 2012 Report. Geneva, Switzerland: WHO and UNICEF; 2012.
  10. Douthwaite M, Ward P. Increasing contraceptive use in rural Pakistan: an evaluation of the Lady Health Worker Programme. Health Policy Plan. 2005;20(2):117-123.
  11. Global Health Workforce Alliance. Pakistan. 2012. Available at: http://www.who.int/workforcealliance/countries/pak/en/index.html. Accessed August 18, 2012.
  12. CHW Technical Task Force. One Million Community Health Workers: Technical Task Force Report. New York, NY: The Earth Institute; 2011. Available at: http://www.millenniumvillages.org/uploads/ReportPaper/1mCHW_TechnicalTas... rt.pdf.
  13. Oxford Policy Management. Lady Health Worker Programme: External Evaluation of the National Programme for Family Planning and Primary Health Care; Summary of Results. Oxford Policy Management; 2009. Available at: http://www.opml.co.uk/projects/lady-health- worker-programme-third-party-evaluation-performance.
  14. Bhutta ZA, Memon ZA, Soofi S, Salat MS, Cousens S, Martines J. Implementing community-based perinatal care: results from a pilot study in rural Pakistan. Bull World Health Organ. 2008;86(6):452-459.
  15. Haq Z, Iqbal Z, Rahman A. Job stress among community health workers: a multi-method study from Pakistan. Int J Ment Health Syst. 2008;2(1):15.

This case study was written by Rose Zulliger, a student in the Johns Hopkins Bloomberg School of Public Health. Zulfiqar Khan, Coordinator (Health System Strengthening), WHO, Pakistan, provided helpful comments on an earlier draft.

Officially, Pakistan has four provinces, one territory, and one capital province. For the purpose of our discussion here, we will refer to all as provinces.


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