Background
Community health workers (CHWs) have become increasingly recognized for their crucial role in enhancing population health, particularly in regions facing shortages of skilled healthcare professionals. Pakistan’s National Program For Family Planning And Primary Health Care, commonly referred to as the “Lady Health Workers Programme,” was initiated in April 1994 by then Prime Minister Benazir Bhutto. This ambitious program aimed to provide universal health coverage across Pakistan, aligning with the Program of Action from the International Conference on Population and Development (ICPD) in Cairo. Driven by a commitment to bring healthcare to the doorstep of millions, this initiative has evolved into one of the world’s largest and most impactful community-based primary healthcare programs, serving over 80 million individuals, predominantly in rural and underserved areas. The cornerstone of the program is the recruitment and training of 100,000 Lady Health Workers (LHWs) nationwide, implemented in phases. These locally recruited, literate women receive comprehensive training in primary healthcare and are deployed within their own communities. Their responsibilities include delivering essential maternal and child healthcare services, encompassing family planning, managing common ailments, and providing vital health education.
The global movement towards improved primary healthcare access for vulnerable populations gained momentum following the Alma Ata Declaration of 1978. Countries like China, Tanzania, Mozambique, and those in Latin America pioneered large-scale community-based health programs. China’s “barefoot doctors” in the 1960s exemplified this approach, delivering basic healthcare to rural populations. Deploying CHWs has become a widely accepted strategy to extend basic healthcare to the community level and bridge the gap between communities and formal health systems, especially in low- and middle-income countries.
Pakistan faced significant challenges in maternal and child health indicators during the 1970s and 80s. Key contributing factors included communication barriers between communities and the national health system, resource constraints, and a disproportionate allocation of resources towards tertiary care, neglecting primary healthcare and rural populations. As a signatory to the Alma Ata declaration, the Pakistani government, in collaboration with the World Health Organization (WHO), launched the Lady Health Worker’s Program in 1994 as its flagship nationwide community-based health initiative. LHWs undergo a rigorous recruitment and selection process outlined in the program’s design. Following recruitment, they complete a 15-month training period, after which each LHW is responsible for serving approximately 1000 people or 150 households, conducting daily visits to 5-7 homes. Currently, over 100,000 LHWs are active across Pakistan, reaching an estimated 60-70% of the population, primarily in rural regions. The government’s annual investment averages PKR 44,000 per LHW.
The program directly contributes to the Millennium Development Goals (MDGs) 1, 4, 5, and 6, and indirectly to MDG 7. With the devolution of Pakistan’s health system in 2011, and provinces now formulating their health sector strategies, it is crucial to evaluate the LHW program’s effectiveness. This paper employs a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis to assess the National Program for Family Planning and Primary Health Care. SWOT analysis is a strategic planning tool used to evaluate the internal and external factors affecting a project or organization. It identifies strengths and weaknesses within the program, as well as external opportunities and threats. This subjective assessment helps determine the likelihood of a program’s success or areas needing improvement. The following analysis is structured around these four SWOT categories.
Methods
The SWOT analysis was conducted through a comprehensive literature review of 22 peer-reviewed articles sourced from Google Scholar and PubMed. The search strategy utilized MeSH keywords including “Primary Healthcare,” “Human Resources for Health,” “Management Information System,” “Lady health worker,” “Vertical program,” “Developing countries,” and “Pakistan.” Studies were selected based on their focus on the National Program for Family Planning and Primary Health Care itself, excluding those that merely used LHWs as data collectors or examined specific service delivery aspects without evaluating the broader program. This approach facilitated an in-depth examination of the program’s structure, operational dynamics, and documented outcomes.
Review
Strengths
Panel 1 highlights the key strengths of the National Program for Family Planning and Primary Health Care.
Panel 1: STRENGTHS
- Political Commitment
- Effective Recruitment and Selection Procedures
- Extensive Coverage and Outreach in Rural Areas
- Integration within the Upper Levels of the Healthcare System
- Well-Defined Management and Supervisory Structures
- Comprehensive Healthcare Service Provision
- Robust Management Information System (MIS)
- Integrated Training of LHWs
- Demonstrable Positive Impact on Health Indicators
- Cost-Effective Intervention
Political Commitment
A significant strength of the LHW program is its sustained political support across different governments in Pakistan since its inception in 1994. This consistent recognition within the political sphere and government sectors has ensured uninterrupted financial and administrative backing, vital for the program’s longevity and scale.
Recruitment and Selection
The program’s strategy of rapidly recruiting, training, and deploying community-based female workers, primarily identified by their own communities, is a cornerstone of its success. This community-driven selection process fosters a sense of ownership and ensures that women chosen for these roles are both accepted and empowered within their communities, leading to improved social standing and livelihoods.
Wide Coverage
The program’s extensive reach, covering 60-70% of Pakistan’s population, predominantly in rural areas, represents a major strength. This wide coverage is achieved through consistent outreach activities, bringing essential healthcare services to remote and underserved populations.
Integration
The program demonstrates integration within the existing healthcare system, particularly at higher administrative levels. This integration, while needing further strengthening at lower levels, allows for coordination and resource sharing within the broader health infrastructure.
Management and Supervisory Structures
The National Program for Family Planning and Primary Health Care is characterized by its comprehensive design, incorporating well-defined implementation and supervisory structures. This includes a tiered system of supervision, from Lady Health Supervisors (LHS) at the local level to District and Provincial Program Officers. LHS are responsible for the regular oversight of 20-25 LHWs, conducting monthly visits and performance assessments. This structured approach to management and supervision has been crucial for program scale-up and integration into the public health system, supported by consistent political will and long-term federal funding.
Comprehensive Health Care Provision
LHWs deliver a comprehensive package of preventive and curative primary healthcare services directly to households. This includes treatment for minor ailments, referrals to first-level care facilities, antenatal care registration, promotion of safe delivery practices, counseling for mothers and newborns, child growth monitoring, breastfeeding and weaning guidance, family planning counseling and services, and provision of essential medicines and contraceptives. This broad service package significantly contributes to achieving national health goals.
Management Information System (MIS)
The program’s Management Information System (LHW-MIS) is a critical strength, serving as the backbone for effective program management. This comprehensive system collects and transmits data on primary healthcare activities and logistics from the local level to national levels. Utilizing nine data collection tools, the MIS supports LHWs in tracking community health status and enables supervisors and managers to monitor performance. Furthermore, it captures household-level data, accounting for healthcare utilization across both public and private sectors.
Training
The program’s facility-based and salaried training program for LHWs is a significant strength. With recognized curricula, standardized protocols, and regular refresher courses, the training ensures that LHWs are well-prepared to deliver essential primary healthcare services effectively.
Impact on Health Indicators
The deployment of community health workers has demonstrably improved key health indicators. By bridging the gap between communities and the formal healthcare system, LHWs have increased healthcare service utilization and raised health awareness through education. Evaluations, including reports from Oxford Policy Management and the Pakistan Demographic and Health Survey, indicate significant improvements in infant mortality rate (IMR), maternal mortality ratio (MMR), and contraceptive prevalence rate (CPR) in areas covered by LHWs. Households in LHW-served communities are more likely to adopt modern family planning methods, receive tetanus toxoid vaccinations, obtain postnatal medical check-ups, and immunize young children. While acknowledging that broader socio-economic improvements contribute to these gains, the LHW program plays a crucial role in these positive health outcomes.
Cost-Effective Intervention
The LHW program is a highly cost-effective approach to delivering primary healthcare in resource-constrained settings. With an annual cost of approximately US$750 per LHW, each worker serves around 1000 individuals. This translates to a service delivery cost of approximately 75 cents per person, making it a remarkably efficient investment in public health.
Weaknesses
Panel 2 outlines the weaknesses identified within the National Program for Family Planning and Primary Health Care.
Panel 2: WEAKNESSES
- Suboptimal Management at Lower Levels
- Limited Integration at Peripheral Levels
- Salary Payment Irregularities
- Job Insecurity
- Inadequate Supplies and Equipment Provision
- Weak Referral Systems
- Poor Integration of MIS with the Broader Health System
- Insufficient Supervision and Linkages with Peripheral Health Facilities
- Variable Quality of Care
- Presence of Non-Performing Contingents
- Slow Progress in Achieving Program Targets
- Limited Impact in Areas Such as Sanitation and Breastfeeding
Management and Integration Challenges
Despite structured management and phased implementation, the LHW program faces management challenges, particularly at lower levels. Frequent staff turnover among supervisory and logistics personnel hinders the development of expertise and continuity, impacting program evolution and quality of care. Performance monitoring reveals inconsistent integration with Basic Health Units (BHUs) and other health programs. Effective integration within the wider health system is crucial for maximizing program impact. Furthermore, reports indicate pockets of LHWs providing substandard care or not actively working, potentially due to delays in planned management and organizational improvements.
Salary and Job Insecurity Issues
Recent delays in salary payments to LHWs have led to widespread protests and negative media attention, damaging the program’s image and demoralizing the workforce. The designation of salaries as stipends, without progressive job security or government employee status after 18 years, contributes to job insecurity and undermines worker motivation. While perhaps deviating from the “barefoot doctor” ethos, addressing job security and fair compensation is essential for maintaining a motivated workforce.
Overburden and Involvement in Multiple Public Health Initiatives
LHWs are often overburdened by involvement in various public health campaigns initiated by donor agencies, NGOs, or health departments, such as Expanded Program on Immunization (EPI), Tuberculosis Directly Observed Treatment Short-course (TB-DOTS), and Malaria control programs. This expanded workload can detract from their core mandate of primary healthcare, family planning, antenatal and postnatal care, nutrition counseling, and immunization.
Weaknesses in Supply and Equipment Provision
Inadequate disbursement of funds and essential supplies at all levels represents a significant weakness. Despite program expansion, evaluations highlight persistent shortcomings in the provision of supplies, equipment, and referral services, requiring urgent attention.
Weak Referral System
A global review of community-based health programs identified weak referral systems as a critical challenge for the LHW program, potentially stemming from rapid integration into a weak national health system. These weaknesses compromise program sustainability, quality of care, and health worker retention.
Poor MIS Integration
Despite the presence of a comprehensive MIS, its limited integration with the broader health system hinders effective decision-making. Lack of seamless data flow from the grassroots level to higher levels impedes informed resource allocation, procurement, and program adjustments.
Insufficient Supervision and Peripheral Linkages
While linkages at higher administrative levels are relatively strong, connections at the field level, particularly with BHUs and peripheral health facilities, are weak. This is often reflective of systemic weaknesses within the broader healthcare infrastructure.
Variable Quality of Care and Non-Performing LHWs
Reports indicate inconsistent quality of care provided by LHWs across different regions. Furthermore, the presence of LHWs who are not actively working but still receiving salaries undermines program efficiency and overall performance.
Slow Progress in Meeting Targets
The program has experienced slower than anticipated progress in achieving its intended targets across various health indicators and service delivery metrics.
Limited Impact on Sanitation and Breastfeeding Practices
While impactful in several areas, the program has shown less success in improving health knowledge related to sanitation and promoting key behaviors such as exclusive breastfeeding for the first six months of life. Impact in areas like neonatal mortality and overall health knowledge also remains limited.
Opportunities
Panel 3 highlights the opportunities available to enhance the National Program for Family Planning and Primary Health Care.
Panel 3: OPPORTUNITIES
- Leveraging Wide Coverage and Social Acceptability for Expanded Interventions
- Utilizing Training Capacity for Broader Healthcare Workforce Development
- Expanding Emergency Obstetric Care Training for Select LHWs
- Harnessing the Program for Health System Research
- Using the Program as a Platform for Women’s Empowerment
- Integrating Program Activities into Poverty Alleviation Strategies
Wide Coverage and Social Acceptability
The program’s extensive coverage and the LHWs’ established social acceptance present opportunities for implementing future public health interventions. In regions where women often require permission to seek care from female providers, LHWs can play a transformative role in shaping healthcare-seeking behaviors and practices.
Emergency Obstetric Care Training
High-performing LHWs could be selected for advanced training and certification in basic emergency obstetric care. Community health workers have proven valuable in bridging service delivery gaps, particularly where deploying skilled personnel is challenging.
Health System Research Platform
The program’s extensive network of LHWs can be leveraged as a valuable workforce for conducting health system research. Their reach and community access make them ideal for data collection and community-based studies.
Women’s Empowerment Catalyst
The program can serve as a catalyst for women’s empowerment within communities. LHWs can facilitate the formation of women’s groups and health committees, fostering community participation in primary healthcare, a fundamental aspect of the Alma Ata declaration. LHWs themselves have emerged as community leaders, particularly in contexts where women’s participation in local politics is limited.
Strengthening Referral Systems
LHWs can be instrumental in strengthening weak referral systems, a persistent challenge in primary healthcare. By actively facilitating referrals for vulnerable populations, especially women and children, LHWs can improve timely access to appropriate care and potentially save lives.
Threats
Panel 4 outlines the threats facing the National Program for Family Planning and Primary Health Care.
Panel 4: THREATS
- Persistent Poverty, Patriarchal Structures, and Restrictive Social Norms
- Risk of Political Interference
- Funding Instability
- Challenging Political and Social Environment
- Potential Resistance from Established Medical Professions
- Risks of Inappropriate Practices and Quackery
Socio-Cultural Barriers
LHWs face ongoing challenges stemming from pervasive poverty, patriarchal societal structures, and restrictive social norms. Poverty limits the adoption of healthy behaviors in the communities they serve. Patriarchal structures and social norms can hinder LHWs’ social mobility and influence within their communities.
Political Interference
The program’s large scale and employment opportunities make it vulnerable to political interference, potentially impacting recruitment, resource allocation, and program integrity.
Funding Instability
Following the 2011 devolution, uncertainty surrounding program funding at the provincial level poses a significant threat. Potential funding gaps could jeopardize program sustainability and disrupt service delivery, causing unrest among LHWs and impacting community healthcare access.
Political and Social Instability
In certain regions, resistance to female leadership and influence, coupled with security concerns, present serious threats. Tragic incidents, such as attacks on LHWs during polio campaigns, highlight the risks they face and underscore the challenging socio-political environment in some areas. Traditional gender norms can also impede LHWs’ effectiveness in delivering maternal and child healthcare.
Resistance from Established Medical Professions
Established medical professions, including doctors, nurses, and lady health visitors, may perceive the LHW program as a challenge to their roles or professional standing, potentially leading to resistance and undermining program progress.
Risks of Quackery
LHWs may face temptation to engage in inappropriate or unproven healthcare practices, particularly within the private sector. Such actions could erode public trust in the program and compromise patient safety.
Discussion
The consistent political commitment to the LHW program has been crucial to its success as a cost-effective means of delivering primary healthcare to underserved populations in Pakistan. The program’s robust design, planning, implementation, and supervision mechanisms, supported by the MIS, provide a strong foundation for continued progress, particularly in the post-devolution context where provinces have greater control over program personnel. The LHW program holds significant potential to further improve primary healthcare indicators in Pakistan. However, strengthening formal referral systems and providing appropriate incentives are essential. While this extensive community-based program has demonstrated its capacity to improve maternal and child survival, aligning with global experiences, addressing the identified weaknesses is crucial to maximizing the productivity and impact of LHWs. Provinces should prioritize expanding service coverage and leveraging the program’s potential for health system research. The program’s positive influence on women’s empowerment and poverty alleviation should also be recognized and further enhanced. Integrating the LHW program into provincial health strategies and establishing clear career pathways for LHWs will reduce politicization and boost worker morale and motivation. Strengthening two-way linkages between LHWs and communities, as well as with first and secondary-level care facilities for timely referrals, is paramount. Enhanced supervision and performance management, focused on improving maternal and child health outcomes, will further optimize the program’s effectiveness.
Conclusion
To fully realize the potential of Pakistan’s Lady Health Workers as the backbone of primary healthcare, sustained political commitment at the highest levels is imperative. The program requires seamless integration into the existing health system, coupled with predictable and equitable remuneration structures for LHWs. Developing mechanisms to ensure job security and enhance motivation for these essential health workers is crucial for the program’s long-term success and its continued contribution to improving the health of Pakistan’s population.
Abbreviations
BHU: Basic health unit; CHW: Community health worker; CPR: Contraceptive prevalence rate; EPI: Expanded program of immunization; FLCF: First level care facility; ICPD: International conference on population & development; IMR: Infant mortality rate; LHS: Lady health supervisor; LHW: Lady health worker; MDG: Millennium development goals; MIS: Management information system; MMR: Maternal mortality ratio; NGO: Non-governmental organization; PHC: Primary health care; SWOT: Strengths weaknesses, opportunities, threats; TB-DOTS: Tuberculosis-directly observed treatment short course; WHO: World health organization.
Competing interests
Authors do not have any competing interests to declare.
Authors’ contributions
“MSW and BTS conceptualized the theme of the paper; MSW carried out the literature review, MSW and BTS synthesized the literature; AA participated in the write up and drafting of the manuscript; BTS added to the intellectual content of the paper. All authors read and approved the final draft of the manuscript.”
Contributor Information
Mohammad Salim Wazir, Email: [email protected].
Babar Tasneem Shaikh, Email: [email protected].
Ashfaq Ahmed, Email: [email protected].
Acknowledgements
Authors are grateful to the management of Health Services Academy and the PhD programme for providing the insights into the idea of this manuscript and for providing access to the library resources.
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