National Program for Family Planning and Primary Health Care in Pakistan: A SWOT Analysis

Introduction

Community health workers are globally recognized as vital in enhancing population health, especially in regions facing shortages of skilled medical personnel [[1](#B1)]. Pakistan’s National Program for Family Planning and Primary Health Care, widely known as the “Lady Health Workers’ Programme,” was initiated in April 1994 by then Prime Minister Mohtarama Benazir Bhutto. This ambitious program aimed to achieve universal health coverage in Pakistan, aligning with the Program of Action from the ICPD in Cairo [[2](#B2)]. Driven by this vision, it has become one of the world’s largest and most impactful community-based initiatives, delivering essential primary health care services to over 80 million individuals across Pakistan, primarily in underserved rural areas [[3](#B3),4]. The core strategy involves training and deploying 100,000 Lady Health Workers (LHWs) nationwide in phases. These locally recruited and literate women receive comprehensive primary health care training and are stationed within their own communities. Their responsibilities include providing crucial maternal and child health services, family planning guidance, managing minor illnesses, and delivering vital health education [[5](#B5)].

Since the Alma Ata Declaration of 1978, global efforts have been underway to improve primary health care access for vulnerable populations [[6](#B6)]. Countries like Tanzania, Mozambique, China, and those in Latin America pioneered large-scale community health programs. China’s “barefoot doctors” in the 1960s set a precedent for delivering basic healthcare in rural settings. Deploying community health workers (CHWs) has become a recognized and effective approach to bridge the gap between health systems and communities in low- and middle-income countries, ensuring basic health services reach those most in need [[3](#B3)].

During the 1970s and 80s, Pakistan faced significant challenges in maternal and child health indicators. Key factors included a disconnect between communities and the national health system, resource constraints, and a disproportionate allocation of resources towards tertiary care at the expense of primary health care and rural populations. As a signatory to the Alma Ata declaration, the Government of Pakistan, in collaboration with the World Health Organization (WHO), launched the Lady Health Worker’s Program in 1994, its first nationwide community-based health initiative [[7](#B7)]. LHWs undergo rigorous recruitment and selection based on program guidelines, followed by 15 months of training. Each LHW is then responsible for serving approximately 1000 people or 150 households, conducting daily visits to 5-7 homes [[7](#B7),8]. Currently, over 100,000 LHWs operate across Pakistan, covering 60-70% of the population, predominantly in rural areas. The government’s annual investment averages PKR 44,000 per LHW [[7](#B7),9].

The National Program for Family Planning and Primary Health Care directly contributes to Millennium Development Goals (MDGs) 1, 4, 5, and 6, and indirectly to MDG 7. With health system devolution in Pakistan in 2011, and provinces now shaping their health sector programs [[10](#B10)], it is crucial to evaluate the LHW program’s effectiveness. This paper employs SWOT analysis—Strengths, Weaknesses, Opportunities, and Threats—to assess the National Program for Family Planning and Primary Health Care. SWOT analysis is a subjective yet valuable tool for evaluating an organization or program’s success potential by examining its internal strengths and weaknesses alongside external opportunities and threats [[11](#B11)]. This analysis provides a structured framework for understanding the program’s current standing and future prospects.

Methods

This SWOT analysis is based on a comprehensive review of literature, including 22 peer-reviewed papers sourced from Google Scholar and PubMed. Search terms included “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. This approach allowed for a thorough examination of the program’s structure, operations, and documented outcomes.

SWOT Analysis of the National Program for Family Planning and Primary Health Care Pakistan

Strengths

The National Program for Family Planning and Primary Health Care in Pakistan exhibits several key strengths that have contributed to its impact and reach. These strengths are outlined below:

• Political Commitment: A significant strength of the program is the sustained political commitment it has received across different administrations since its inception in 1994. This bipartisan support has ensured consistent financial and administrative backing, crucial for the program’s longevity and expansion.

• Effective Recruitment and Selection Procedures: The program’s strategy of community-based recruitment of female health workers is a major strength [[12](#B12)]. By involving communities in identifying suitable candidates, the program fosters local ownership and trust. This process not only empowers women by providing them with employment opportunities but also enhances their social standing and overall quality of life.

• Wide Coverage and Outreach: As one of the largest community health programs globally, it achieves extensive coverage, reaching 60-70% of Pakistan’s population, primarily in rural and underserved areas. This wide outreach ensures that primary health care services are accessible to a vast population that would otherwise have limited access.

• Integration within the Healthcare System: The program is designed to integrate with the existing healthcare system, particularly at higher levels of administration. This integration facilitates coordination, resource sharing, and a more streamlined approach to healthcare delivery.

• Well-Defined Management and Supervisory Structures: The program boasts comprehensive management and supervisory frameworks, ensuring structured implementation and monitoring. Lady Health Supervisors (LHS), District Coordinators, and other officers at various levels oversee LHWs, ensuring regular performance evaluation and support. The phased scale-up of the program, combined with a focus on robust management, has been critical to its success [[13](#B13)].

• Comprehensive Healthcare Provision: LHWs deliver a broad spectrum of preventive and curative primary healthcare services directly to households. This includes treating minor ailments, providing antenatal and postnatal care, family planning counseling and services, child health services like immunization and nutrition advice, and health education. This comprehensive package addresses critical health needs at the community level [[13](#B13)].

• Robust Management Information System (MIS): The LHW program’s MIS is a vital strength, systematically collecting and managing data on all program activities. This system tracks health service delivery, logistics, and program performance, enabling data-driven decision-making at all levels—from local to national [[7](#B7)].

• Effective Training Programs: The program includes facility-based, paid training for LHWs, utilizing standardized curricula and protocols, along with regular refresher courses. This ensures LHWs are well-prepared and continuously updated on best practices in primary health care.

• Positive Impact on Health Indicators: Numerous evaluations have demonstrated the program’s positive impact on key health indicators. By bridging the gap between communities and the formal healthcare system, LHWs have improved health service utilization and promoted health awareness. Studies, including the Demographic and Health Survey of 2006-2007, have shown significant improvements in infant mortality rate (IMR), maternal mortality ratio (MMR), and contraceptive prevalence rate (CPR) in program areas [[7](#B7),8].

• Cost-Effective Intervention: The services provided by LHWs are highly cost-effective. With an annual cost of approximately US$750 per LHW serving 1000 people, the program delivers essential healthcare at a low cost per person, making it a sustainable model for resource-constrained settings [[14](#B14)].

Weaknesses

Despite its strengths, the National Program for Family Planning and Primary Health Care in Pakistan faces several weaknesses that hinder its optimal performance and impact. These weaknesses need to be addressed to enhance the program’s effectiveness:

• Management Issues at Lower Levels: Despite well-structured management at higher levels, the program faces management challenges at the operational level. Frequent staff turnover among supervisors and logistics personnel disrupts program continuity and impedes the development of experienced leadership [[15](#B15)].

• Poor Integration at Lower Levels: Integration with existing health services, especially at Basic Health Units (BHUs) and peripheral levels, is often weak or inconsistent. This lack of seamless integration limits the program’s synergy with the broader health system and can lead to inefficiencies [[1](#B1)].

• Salary Payment Issues and Job Insecurity: Recurring delays in salary payments to LHWs have led to widespread protests and negatively impacted worker morale and program image [[17](#B17)]. Furthermore, the lack of permanent government employee status for LHWs creates job insecurity, potentially affecting motivation and long-term commitment.

• Overburdening of LHWs: LHWs are often tasked with additional public health activities beyond their primary responsibilities, such as polio campaigns, TB DOTS, and malaria control [[18](#B18)]. This overload can detract from their core primary healthcare duties, impacting the quality and focus of their services.

• Weak Supply and Equipment Provision: Deficiencies in the supply chain and distribution of essential equipment and resources at all levels hamper the program’s effectiveness [[11](#B11)]. Consistent and reliable provision of supplies is crucial for LHWs to perform their duties effectively.

• Weak Referral Systems: The program suffers from weak referral systems, limiting its ability to effectively connect patients with higher levels of care when needed [[19](#B19)]. This is partly due to integration challenges within a generally weak national health system.

• Poor Integration of MIS with the Broader Health System: While the LHW program has its own MIS, its lack of integration with the overall health system MIS limits its utility for broader health sector planning and decision-making [[14](#B14)].

• Inconsistent Supervision and Linkages with Peripheral Health Facilities: Despite structured supervision, actual supervision quality and effective linkages with BHUs and other local health facilities are inconsistent, hindering program effectiveness at the grassroots level.

• Variable Quality of Care and “Sinecure Contingents”: Reports indicate variable service quality across different regions. In some areas, “sinecure contingents” of LHWs may exist, drawing salaries without actively working, which undermines the program’s overall performance.

• Slow Progress in Meeting Targets: The program has experienced slower than anticipated progress in achieving some of its key targets, indicating potential operational and implementation bottlenecks.

• Limited Impact in Specific Health Areas: The program has shown less impact in areas such as sanitation, promoting exclusive breastfeeding, and improving health knowledge compared to other areas like immunization and family planning [[3](#B3),13].

Opportunities

The National Program for Family Planning and Primary Health Care in Pakistan has significant opportunities to expand its impact and contribute to broader development goals. Key opportunities include:

• Leveraging Wide Coverage and Social Acceptability: The program’s extensive reach and the LHWs’ social acceptance within communities provide a platform for expanding public health interventions. LHWs are uniquely positioned to address healthcare-seeking behaviors, particularly among women in remote rural areas who prefer female healthcare providers [[20](#B20)].

• Utilizing Training Capacity for Broader Health Initiatives: The program’s established training infrastructure and expertise can be leveraged to train other cadres of health workers or to implement new health initiatives, maximizing resource utilization.

• Expanding Roles to Include Emergency Obstetrical Care: Selected LHWs, based on performance and aptitude, could be trained and certified to provide basic emergency obstetric care in underserved areas, addressing critical gaps in maternal healthcare access [[21](#B21)].

• Contributing to Health System Research: The large network of LHWs can be mobilized as a valuable workforce for health system research, enabling data collection and community-based studies to inform policy and program improvements.

• Empowering Women Beyond Health: The program can serve as a catalyst for broader women’s empowerment. LHWs can facilitate women’s groups and health committees, promoting community participation and women’s leadership in local contexts [[22](#B22)]. LHWs themselves are emerging as community leaders, enhancing women’s roles in society.

• Supporting Poverty Alleviation Strategies: By improving community health and empowering women, the program indirectly contributes to poverty alleviation. Healthier communities are more productive, and empowered women contribute more actively to household and community economies.

• Strengthening Referral Systems: LHWs can play a pivotal role in strengthening referral systems, ensuring vulnerable populations, especially women and children, receive timely and appropriate care at higher-level health facilities [[23](#B23)].

Threats

The National Program for Family Planning and Primary Health Care in Pakistan faces several threats that could undermine its effectiveness and sustainability. These threats need to be proactively addressed:

• Poverty, Patriarchy, and Social Norms: Persistent poverty and deeply entrenched patriarchal social norms pose significant challenges to the program’s success. These factors can limit the adoption of healthy behaviors and hinder women’s mobility and agency, impacting both LHWs and the communities they serve [[24](#B24)].

• Political Interference: The program’s large scale and employment opportunities make it vulnerable to political interference in recruitment, postings, and resource allocation, potentially compromising meritocracy and program integrity.

• Funding Instability: Post-devolution, the financial mechanism for the program at the provincial level remains uncertain. Potential funding gaps could severely impact program operations, worker morale, and service delivery to vulnerable communities.

• Challenging Political and Social Environment: In some regions, resistance to female leadership and gender inequality can hinder LHWs’ effectiveness. Tragic incidents, such as attacks on polio workers, highlight the security risks and social opposition LHWs may face [[25](#B25),26].

• Resistance from Established Medical Professions: Some established medical professionals may view LHWs as encroaching on their roles, potentially leading to resistance and undermining the program’s integration within the broader healthcare system.

• Risk of Quackery: LHWs, if not adequately supervised and supported, might be tempted to engage in inappropriate private practices, eroding public trust in the program and potentially leading to malpractice issues.

Discussion

The National Program for Family Planning and Primary Health Care in Pakistan has demonstrated significant political endurance and has proven to be a cost-effective approach to delivering primary healthcare to remote and underserved populations. Its comprehensive design, robust MIS, and established management structures provide a solid foundation for continued success, especially within the devolved provincial health systems [[27](#B27)]. To further enhance its impact, formalizing and incentivizing referral systems is crucial. While the program has shown potential for improving maternal and child survival, mirroring successes in other regions, addressing its weaknesses is essential to maximize the productivity of LHWs [[28](#B28)]. Provinces should focus on expanding service coverage and leveraging the program’s research potential. The program’s contributions to women’s empowerment and poverty alleviation should also be recognized and further strengthened [[24](#B24),29]. Integrating the program into provincial health strategies and establishing clear career pathways for LHWs will enhance their motivation and reduce politicization [[30](#B30)]. Strengthening linkages both with communities and with first- and second-level care facilities is vital for effective referrals [[5](#B5)]. Enhanced supervision and performance management are also essential for improving service delivery and achieving better maternal and child health outcomes [[16](#B16),23].

Conclusion

To fully utilize the robust primary healthcare workforce of Lady Health Workers in Pakistan, sustained political commitment at the highest levels is paramount. Proper integration of the program within the existing health system, coupled with predictable and fair remuneration structures for LHWs, is essential. Developing mechanisms to ensure job security and enhance worker motivation are crucial steps to maximize the effectiveness and long-term sustainability of the National Program for Family Planning and Primary Health Care.

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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