Lady Health Workers: The Heartbeat of Community Healthcare in Pakistan

In the heart of Pakistan’s rural and urban slums, a dedicated group of women have been driving change in the healthcare landscape. The Lady Health Worker (LHW) program, established in 1994, was created to bridge the gap in primary healthcare access, particularly for underserved populations. Over the years, it has grown into a vital force, with 85,000 to 90,000 LHWs now working across all five provinces. These community-based women play a pivotal role in transforming health outcomes, offering essential services that reach those who need them the most.

Initially, the LHW program focused on providing family planning services, such as distributing oral contraceptives, condoms, and offering injectable contraceptives. It also addressed maternal, newborn, and child health (MNCH). Over time, as the program proved successful, LHWs expanded their scope to include additional health services, such as the community management of TB (through DOTS treatment), health education on HIV/AIDS, polio surveillance, and participation in the Expanded Programme on Immunization (EPI).

LHWs have consistently been on the frontlines during disasters and emergencies, including the 2005 earthquake, the 2010 floods, and the COVID-19 pandemic. During COVID-19, they were crucial in raising awareness, identifying cases, educating the public, and providing support to patients in quarantine and isolation. Beyond their designated areas, they have continued to restore essential primary healthcare services, making a significant impact not just within their communities but also in areas outside their catchment areas.

Lady Health Workers are salaried professionals employed by the Department of Health, attached to local health facilities but primarily serve their communities from the comfort of their own homes. The program originally required LHWs to have at least 8 years of education, but this threshold has now been raised to 10 years, ensuring better career prospects for the workers and aligning with government service standards.

The training process for Lady Health Workers (LHWs) is structured and multi-tiered to ensure they are well-equipped to provide quality healthcare. It begins with specialized training for Provincial and District Master Trainers, who then train health facility staff. These trained professionals, in turn, educate LHWs.

The training program begins with an intensive three-month period of classroom-based and clinical instruction conducted at healthcare centers. This is followed by a nine-month phase of practical fieldwork, during which LHWs also participate in monthly classroom sessions. This structured approach equips them with the necessary skills to cater to the varied healthcare requirements of their communities. To maintain and enhance their competencies, LHWs undergo monthly refresher courses and an annual 15-day advanced training program.

After completing three months of intensive training, each LHW is deployed to her designated catchment area, where she operates under the guidance and support of her Lady Health Supervisor (LHS) and the local health facility staff. Her first task is to map out her catchment area, a vital step in understanding the community she will serve. With this map as a foundation, she then registers all households and family members in the "family" (Khaandan) register, creating a comprehensive record that serves as the backbone of her work. Additionally, she fills out the area information chart, capturing key data to help tailor healthcare interventions and track progress over time.

LHWs are entrusted with the important responsibility of registering households within their community, typically covering 150-200 households, which represent around 1,000 to 1,500 individuals. To ensure thorough care, they visit 7-10 households daily, making sure that every household in their area is reached at least once a month. Their role extends beyond simple registration; LHWs create a trusted "Health House" in their own home, where they set up a designated ‘kit corner’ to provide counselling, health advice, and treatment services to those who visit. This setup fosters an environment of accessibility and trust within the community.

Moreover, the 'Health House' serves as a crucial vaccination post, where LHWs collaborate with local vaccinators to ensure that women and children receive their necessary immunizations. LHWs also take on a leadership role in organizing their community, forming health committees and women's groups to promote collective health and well-being. Remarkably, over 80% of their work time is dedicated to household visits, reflecting their commitment to personalized care and community engagement.

At the end of each month, the LHW submits a detailed report during the ‘continuing education’ meeting at the local health facility. This report not only highlights her activities and progress but also helps in identifying any areas that need further attention. During the meeting, she receives restocked medicines and supplies that were used throughout the month, ensuring she stays fully equipped to carry on her vital work in the community.

The 2019 performance evaluation of the Lady Health Worker Program (LHWP) by UNICEF and Oxford Policy Management (OPM) shed light on several systemic challenges that have hindered the program's full potential. These challenges included a freeze on new recruitments following the regularization of LHWs, which strained the program's ability to meet growing demands. Additionally, the increasing scope of responsibilities, particularly in the polio program, added pressure to LHWs, who were already juggling their core duties. Funding deficits and irregularities further exacerbated the issue, leading to shortages in supplies and equipment and limiting the regularity of essential training for LHWs.

Despite these obstacles, the LHWP has continued to make a meaningful impact in areas such as family planning and maternal care. According to UNICEF and OPM's performance evaluation report (2019), contraceptive use has been significantly improved, with a 5% increase in usage and heightened awareness within communities about available options. The program has also played a crucial role in maternal health, boosting the likelihood of women receiving their two required tetanus injections by 8–11%, and encouraging more women to take iron tablets during pregnancy. Although the program’s effect on infant care and immunization rates has been more limited, it has made notable strides in polio prevention.

In conclusion, the Lady Health Worker Program stands as a cornerstone of Pakistan's healthcare system, especially in reaching marginalized communities where healthcare services are often limited. While the program has faced significant challenges, including resource constraints and increased responsibilities, its impact on family planning, maternal health, and public health education remains undeniable. The dedication of LHWs, who serve as trusted figures in their communities, continues to drive positive change. However, to ensure the program’s sustainability and future success, addressing issues like funding, recruitment, and training will be crucial. With continued investment and support, the LHWP has the potential to further transform the health landscape, empowering communities and improving lives across the country.

For further reading and references, see the list below:

• Women Deliver. "Pakistani Lady Health Worker Program: Providing Care to Underserved Populations." Retrieved from: https://womendeliver.org/pakistani-lady-health-worker-program-providing-care-underserved-populations/

• The Challenge Initiative. "Community Health Workers (CHWs) in Pakistan." Retrieved from: https://tciurbanhealth.org/courses/global-chws-hips/lessons/pakistan-community-health-workers/

• Lady Health Workers Strategic Plan 2022-2028 (M/o NHSR&C)

• PubMed. 'Lady health workers programme in Pakistan: challenges, achievements and the way forward' Retrieved from: https://pubmed.ncbi.nlm.nih.gov/21465929/

• UNICEF and Oxford Policy Management (2019). Performance Evaluation of the Lady Health Worker Program in Pakistan.

• World Health Organization (2020). The Role of Community Health Workers in Global Health.

• Integrated Health Project (IHP). "Lady Health Worker Program." Retrieved from: https://ihp.gkp.pk/lhw/