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 provinces 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.

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.

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. 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. 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. 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).

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. 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.

What type of program has been implemented?

LHWs are deployed across the nation in all five provinces of Pakistan. These workers are attached to a local health facility, but they are primarily community based, working from their homes. The homes of LHWs are called Health Houses; emergency treatment and care are provided therein. 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.

LHWs have a broad scope of work that includes 22 different tasks. 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. 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.