INTRODUCTION

Following the Alma-Ata declaration in 1978, many countries initiated developmental programs to improve the health status of the general population¹. Under this initiative, thousands of first level care facilities (FLCFs) were set up all over Pakistan increasing access to primary health care (PHC) from 20% to over 60% in many areas across the country².However, the health indicators still remain dismally poor, particularly maternal and infant mortality^3,4 .

For achieving universal health coverage by addressing PHC at community level, the Government of Pakistan launched the National Program for Family Planning and Primary Health Care in April 1994. The program recruits local, literate girls as Lady Health workers (LHWs), and after 3 months of classroom sessions and 12 months of field training, LHWs provide essential maternal and child heath and family planning services, management of common ailments and health education to the general population. Services of LHWs have also been utilized in other programs like Direct Observation Therapy Short Course (DOTs) for Tuberculosis and polio immunization campaigns. In addition, LHWs collect information regarding basic health indices and utilization of services, which is aggregated at the national level and form an important part of national health statistics⁵.

Independent evaluations of the Program conducted to date have shown mixed results, with some regions in the country performing better than others. The evaluation conducted by the Oxford Policy Management, UK, reports that the performance of about 17% of LHWs were poor and 35% were below average. Moreover, the Governments’ decision to introduce a more comprehensive reproductive health package⁵ would increase LHWs responsibilities and could further decrease efficacy. Therefore, efforts must be focused to strengthen the program and increase the LHWs capacity as efficient health care workers.

Although, any ‘expert’ can objectively evaluate a program using standard indicators, the very workers performing are in the best position to identify their problems and must be consulted while making any policy recommendations.⁶ Very little literature exists which has identified social and cultural, along with organizational barriers to efficient working of LHWs. Furthermore, no study has so far looked at LHWs perspective of the strengths and weakness of the program and how their role in PHC may be strengthened within the program. Therefore, the objectives of this study are 1) to identify the problems face by the LHWs in performing different tasks in the program and 2) to develop recommendations for strengthening LHWs’ role in Primary Health Care in Pakistan in consultation with the LHWs themselves.

MATERIAL AND METHODS

This study was conducted from March to August 2002 in the District West of Karachi- the largest District of the city⁷. About 900 LHWs are currently providing primary health coverage in Karachi, among whom 337 are based at various Basic Health Units in the District West.

A qualitative approach based on key informant interviews was used to gather the data. Semi structured interviews with the help of an interview guide, were conducted to intensively investigate the topic under study. The content of the interview was based on an outline prepared after reviewing various reports and studies concerning LHWs performance and overall achievement of the National program.^{9, 10}

Based on the existing documents, broad categories for interviews (reason for joining the program, training, workload, strength/weakness of the program, suggestions and recommendations) were defined and interviewees were asked to give their view on the various topics pertaining to the program. In addition, a checklist, consisting of a summary of recommendations suggested by the experts and compiled by the Principle Investigator from various studies and reports, were administered and interviewees were asked to agree or disagree to the recommendations.

Study subjects (LHWs, LHW supervisors, medical officers) were selected on the basis of their experience. The interviews were audio taped and the written notes were also taken. The audiotapes were transcribed and emerging themes were categorized. Data was presented in narrative forms using summative and verbatim quotes. Analysis was carried out by grouping similar responses in a matrix and then analyzed with reference to context.

RESULTS

A total of 20 interviews were conducted, 14 respondents were LHWs, 4 were LHW supervisors and 2 were medical officers (District coordinator and the District Health Education Officer). Responses are grouped under the following headings.

Reason for joining the program

The majority joined the program because of financial reasons and also because they enjoy doing social work and an opportunity to “serve humanity”. Several women said that the job timings were very convenient and because they were to serve in their own localities it was very convenient for them to get permission from their families to work. The fact that it is a government job was also an important motivation to join the program.

Number of LHWs

The officers interviewed reported that for a population of 2.3 million there are only 337 LHWs in the District, covering only 300,000 individuals. One LHW reported that in her area, only 4 LHWs are appointed over a population of 12,000. LHWs complained that often they had to attend clients who were not in their assigned localities.

Training of LHWs

All LHWs reported that the initial 3 months training was of very good quality. However, the LHWs were not happy with the attitudes of the doctors in the hospitals where they received. They complained that doctors did not give them enough attention. When asked about further training needs, they all mentioned knowledge regarding common diseases (Tuberculosis, Hepatitis, Acute Respiratory Tract Infections, Malaria and Eye diseases) that they encounter in routine. They also wanted to acquire skills like blood pressure recording, administering injections/infusions and first aid. Officers interviewed supported the aforementioned educational/training needs, and suggested regular refresher courses. Many LHWs also showed interest in midwifery training.

Workload:

The majority thought that ‘considering the salary’ workload is too much. Particularly mentioned was the LHWs involvement in the Polio eradication campaigns was an added workload that hampered their assigned regular work. One of the supervisor reported that the loading and unloading of medicines and transportation of stocks, both of which are not in their job description, took up considerable amount of their time.

When asked about LHWs capabilities of doing more work, the majority said that they are definitely capable of, and are willing to do more, provided their salaries are increased. The officers supported the views and thought it is unrealistic and unfair to expect LHWs to do more work on such a meager pay.

Community expectations:

Provision of drugs and contraceptives was reported to be the greatest expectation of the community.

Table-1: Health workers views about the National Program for Family Planning and Primary Health Care Program (Karachi Pakistan, August 2002).

Recommendations	LHWs		Supervisors		Officers
Recommendations	Yes	No	Yes	No	Yes	No
Mismatch between job description and training be reviewed	3	11	2	2	0	2
Salaries should be increased	14	0	4	0	2	0
Disbursement of salaries be regularized	14	0	4	0	2	0
Follow up of referrals at FLCF be improved	14	0	4	0	2	0
Work load of LHW^± should be decreased	14	0	2	2	2	0
Even distribution of LHW be maintained	14	0	3	1	2	0
Improve knowledge base and technical competence	14	0	4	0	2	0
Improve government FLCF* quality	14	0	4	0	2	0
Improvement in status of women through an indirect effect of program be put in	13	1	4	0	2	0
Capacity for tasks to be carried out must be ensured	14	0	4	0	2	0
Feedback to LHWs must be given	14	0	4	0	2	0
Refresher training courses should be provided	14	0	4	0	2	0
Empower LHWs to voice problems	14	0	4	0	2	0
Improve supply of drugs/logistics	14	0	4	0	2	0
Termination of chronic poor performers	9	5	1	3	0	2
Multi-sectorial support with other departments	14	0	4	0	2	0
Improve access to transport by supervisor	14	0	3	1	2	0
Reporting tools be made simpler	6	8	4	0	1	1

*First Level Care Facility ^± Lady Health Worker

This was also considered a major source of demotivation for the workers because when the program started plenty of drugs were available.

The community also expects the workers to accompany them to the First Level Care Facilities (FLCFs) or other health centers with them because

people thought that they would get better attention at the facilities this way. One of the LHW mentioned that the community perhaps “expects too much” because the LHW is considered as a “Doctor” and must be able to answer all their questions regarding their medical problems.

The LHWs are also constantly approached to sort problems like water shortages and sanitation because the community feels that they are well known in the government sector and can mobilize the municipal corporation into action.

Treatment of referrals at First Level Care Facility:

Most of the LHWs thought that the staff, and in particular the doctors did not give them the due respect. When they accompanied their clients to the health centers, doctors would often make remarks like “what sort of a health worker are you if you can’t manage this yourself?” The LHWs believed that such an attitude undermined their credibility in the community and made it very difficult for them to convince the people to visit the health facilities when required. However, they reported that the family planning services treat their referred clients with more respect.

Future objectives of workers:

LHWs and supervisors reported that they could not progress if they remained in the program. Three of the 14 LHWs said that they would like to be supervisors; the others did not feel that the program offered them any chance of progress. One LHW mentioned that in her locality, out of 32 LHWs initially contracted, only 6 remained.

Strengths of the Program:

All interviewees were asked what they considered the strengths of the program. Their responses are listed below in order of frequencies.

- The program provides 24 hours of basic health services to the community at the doorstep. Thus access to health care is provided to all, especially to women, who for cultural reasons could not leave their houses.

- The hiring of local girls contributed in the high level of acceptability and trust that LHWs enjoyed in communities.

- The program had a positive affect on prevention of important public health concerns (reduction in maternal moralities in their areas, pre-post natal care, demand for tetanus vaccine).

- Increased community acceptance of several culturally sensitive issues like family planning.

- Income generation for a large number of women.

- -Strengthening the health system by increasing linkages between the community and FLCFs.

Weaknesses of program

Interviewees were also asked about what they considered to be weaknesses of the program. Their responses are listed below in order of the frequency with which they were quoted:

- The salary is ‘too low’ and payment is irregular.

- The ‘contractual’ nature of the job is a constant threat and a source of anxiety.

- Political influence and nepotism in selection of LHWs.

- Poor supply of medicines, contraceptives and other logistical support.

- Loss of motivation due to equal treatment of good and poor performers; “although regular, feedback is only given for mistakes made and the supervisors rarely encourage LHWs”.

- A lack of trained people in the management.

- Too much training material and very little emphasis on skills development, inaccurate reporting by the LHWs, too much filed work, too much reporting and traveling which is difficult and expensive.

DISCUSSION

This study aimed to discuss the problems LHWs face in carrying out their duties, and develop recommendations for strengthening the program in consultation with LHWs.

Reasons for joining

The program is responsible for providing an extra source of income, an opportunity for women to do social work, obtain a sense of achievement in their lives and thus improve their social lives as well. Due to the convenient timings of the job and their own areas in which they serve, LHWs are able to take care of their household responsibilities and at the same time function as productive members of society. In our opinion, the program has both direct and indirect effects towards empowering women and improving the status of women and hence plays an important role in the development of women. According to Asian Development Bank report improvement in the status of women must be integrated into the program⁸.

In Pakistan, a government job is not only considered as an indication of social status but also gives a sense of job security. Incidentally, the fact that these workers are contractual with no government benefits is one of the greatest de-motivator and a cause of anxiety. Although it will have substantial financial implications for the program, the well-deserved raise in salary and government benefits will be motivation for workers to work harder, not engage in covert employment which may compromise their work and decreases the over all drop out rate.

Number of Lady Health Workers:

To facilitate an increase in work force of LHWs, the Government, from July 1, 2001 has merged the Village Based Family Planning Workers scheme being run by the Ministry of Population and Welfare with the national program. This has added another 13,000 workers to the program. In the long run, the Government plans to employ 100,000 workers by 2005 to increase 100% coverage¹². With the devolution process in full swing, even managerial staff is short in supply. The Government must ensure that there is an acceptable number of all cadres of appropriately trained employees to ensure smooth running of the program.

Training of LHWs:

Even though reports have suggested that there is a mismatch between training and job description^{9, 11}, most of the LHWs disagreed, and were of the opinion that the quality of training is good. Another area that was pointed as deficient by LHWs and supported by expert recommendations was communication skills (counseling) and clinical skills (blood pressure recording and administering injections/infusions)^{10, 11}.

Since LHWs have the records of all completed and on-going vaccinations in their areas, it could be practical to declare the LHWs ‘health house’, a ‘vaccination center’ as well. It is worth mentioning that at present all government vaccinators are men, and due to cultural issues, many women refuse to be vaccinated. LHWs may be able to convince women to get vaccinated simply by the fact that they are women themselves. Declaration of LHW house as a vaccination center will cut costs of the vertical Extended Program of Immunization (EPI) and integrating the EPI service as a horizontal program.

Based on criteria of performance and personal objectives, training in safe delivery and midwifery could be an attractive incentive and would give LHWs an added skill which they could use to earn extra income and at the same time contribute to decrease maternal mortality. One may argue that this would take up more of their time. On the contrary, we believe that since LHWs accompany mothers for antenatal check up to FLCFs, it could, perhaps even spare their time if they could conduct deliveries in their own neighborhoods. One may also assume that managing quality of deliveries by LHWs will be easier than it is to regulate the Traditional Birth Attendants (TBAs), who are often not officially trained.

LHWs also stressed on the importance of frequent refresher courses as did the supervisors. This view was also supported by the officers who particularly mentioned regular refresher courses for the Management Information Systems (MIS) and has also been suggested by a UNICEF report¹⁴.

Workload

LHWs are constantly involved for activities other than their regular tasks. Involving the LHWs in Directly Observed Treatment Short course (DOTS) in one province of the country has yet to be evaluated, but informal discussion with some officers suggest that it may be a success. It has been suggested that LHWs may be the answer to the problem of access to health care facilities while reviewing the DOTS program in Pakistan⁹. However, although the LHWs may be capable of, it is highly unfair that they be given to do additional assignments without a raise in their salaries or other benefits. This might even compromise the quality of services being given.

Officers and supervisors were similarly overburdened with responsibilities that did not fall into their regular job description. The officers complained that extra activities like the polio eradication campaigns took up a lot of program time and interfered with their managerial activities. Since it is an activity that both workers and officers are reluctant to take part in, and causes hindrance in their work schedules, officers, supervisors and LHWs should not be involved in these campaigns.

Community expectations

Researchers have identified ‘increasing and often incompatible’ demands on LHW services¹⁷. Community expects “home service” every time they are in need of medical care. It has been shown that women who can obtain the service at their doorstep are more likely to use family planning. However, poor supply, as is often the case, causes “embarrassment” and made LHWs suspect in the eyes of the community because they were accused of selling drugs and contraceptives in the market. The fact that many consider LHWs as ‘doctors’ is a dangerous one, considering the risk of malpractice and the high number of quacks already operating nation wide¹³. It may be prudent to educate people about the role and capabilities of the LHW by advertisements.

LHWs are also approached by the community for other problems like sanitation and clean water. We believe that this may be capitalized by developing linkages between the program and the local municipal corporations whereby, LHWs may have the right to lodge complaints on behalf of the community or even be part of a surveillance mechanism. Several LHWs suggested that they have formal linkages with local non-governmental organizations. This could help them mobilize and empower communities as was done in the famous Orangi pilot Project in Karachi¹⁴.

Referral system

A proper referral system regulates appropriate mix of cases for a particular level of health facilities; hence providing appropriate and cost-effective treatment to patients^10,15. However, the referral system in the public sector is not an effective one. The LHWs may be used as a gate-keeping mechanism to regulate the over all flow of patients and prevent over logging of higher- level health facilities.

LHWs referral rate is approximately 55% with most cases being referred for different conditions¹⁰. In this study, LHWs were not very satisfied with the referral system because their referrals were not given priority at the health facilities. This underscored their credibility in the community as it often took them considerable effort to convince people to visit the referral sites in the first place, and when patients were not treated well, people would not listen to them a second time. Priority should be given to cases referred by the LHWs.

Future objectives of workers

The drop rate of LHWs is quite high and the majority of the respondents said that the program did not have any chance for promotion and would join a better paying job if they got the chance. Career development is a very important motivator and workers should be given chances to enhance their qualifications and skills to attain better financial rewards and promotions^16,17.

Logistical support structure

Insufficient logistical support is a major issue and causes great difficulty for the staff. Supervisors should be provided vehicles, or compensated with an appropriate travel allowance. Another weakness pointed out was a lack of trained people in low and middle management. The program must arrange training for middle managers and make stringent criteria for selection.

Limitations of the study

Due to time and budget constraints, the study was restricted to one district only and the problems identified by LHWs may not necessarily apply to other regions in the country. However, some of the cross cutting issues reported in this study, may very well hold true for other regions as well.

CONCLUSIONS AND RECOMMENDATIONS

After a decade of the National Program for Family Planning and PHC has acquired maturity, and has expanded from a limited pilot project to an enormous program with nation wide coverage. The workers form an invaluable body of skilled human resource, the services of whom are often utilized for many other programs. LHWs have mostly succeeded in establishing trust and community acceptability and are providing essential PHC services across the country. This is all the more significant in a culture where government programs are considered suspect by most. The following recommendations are being made with the aim to strengthen the role of LHWs in PHC in Pakistan.

· LHWs should be made permanent government employees with all relevant benefits after an initial probation period.

· Salaries should be increased and salary disbursement mechanism be made efficient.

· Eligible LHWs be given incentives (skills, career development, financial) and positive feed back for motivation

· Community be educated about assigned role and responsibilities of LHWs

· Program staff must not be involved in other programs like Polio eradication campaigns

· Patient referral system by the LHWs must be strengthened and referrals by LHWs be given priority at FLCFs

ACKNOWLEDGEMENTS

We are extremely grateful to Drs. Ross Plowman and Lorna Guinness (Faculty, London School of Hygiene and Tropical Medicine) for their feedback on the proposal of study.

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