Structure of the Lady Health Workers Program in Pakistan.

Overall goal of the LHWP (Lady Health Workers Program) was to contribute to poverty reduction by improving the health of the people of Pakistan. The main objective was to increase utilization of primitive, preventive and curative services at the community level particularly for women and children in poor and underserved areas. In order to achieve these aims and objectives, the Programme recruited local women (LHWs) and trained them to provide family planning services and primary health care in their own communities.

These LHWs are recruited through a well defined process according to strict selection criteria, which is, age between 18-45 years, being a local resident, at least 8 years of schooling, preferably married, and being acceptable to the community. Recruitment of LHWs is followed by 15 months of basic training at the First Level Care Facility (Basic Health Unit and Rural Health Center) or Tehsil headquarter hospital, by the staff working over there in two phases, using Programme training manuals and curriculum.

First phase of basic training is of five days a week for three months. The second phase of training lasts for 12 months with three weeks of field work followed by one week of classroom training each month. The basic training of the LHWs is complemented by one day "Continuing Education Session" each month and 15 days "Refresher Training" on various topics every year. One LHW is responsible for approximately 1000 people, or 150 homes, and visits 5 to 7 houses daily. The scope of work and responsibility of LHW includes over 20 tasks, ranging from health education in terms of antenatal care and referral, immunization services and support to community mobilization, provision of family planning and basic curative care.

Moreover, the house of each LHW has been declared as a Health House where people can come in case of emergency to receive basic treatment or guidance. The LHWs are also accountable for maintaining comprehensive records for all patients under their charge by updating family register at the health house to reflect medical histories and health conditions of each member. Moreover, they also send their monthly reports containing information about indicators of maternal and child health, family planning and basic curative care. Hence, this meticulous record keeping allows the LHWs to keep track of individuals in order to proactively provide services. Quality of care by the LHWs is maintained through a well established supervisory network from the community up to the Federal level. The monitoring and supervisory cadres include Lady Health Supervisors at a ratio of 1:20-25 LHWs, Field Programme Officers and the management setup at the District, Provincial and Federal level.

Currently, approximately 93,000 LHWs are working across all the districts of Pakistan, providing PHC services to the population of rural and urban slum areas. Each LHW is supplied with basic items for her health house and essential drugs to treat minor ailments in addition to contraceptives. All of these contraceptives and supplies are provided free of cost, to the population, in the catchment area of each LHW. The procurement system for these supplies is central. However, the demand is generated from districts and a consolidated tender for drugs, non drug items and stationary is advertised annually from the federal office. In the last project period, the average cost of each LHW was approximately Pak Rs 44,000 (US$ 570 approx) per year. This included their salary (more than 50% of the total), medicine and supplies, management costs, supervision and training costs for the whole year. The entire budget was provided by the government of Pakistan. The Programme design is such that it has a strong network of implementation units at federal, provincial and district levels 

The structure is well defined in its responsibilities at each level and is strongly linked with the district and provincial governments. The Programme is headed by a National Coordinator, who is posted at the federal programme implementation unit. In its current structure, the Programme can be seen to be centrally funded and directed from the Federal level, but the key operational decisions are taken at the provincial, district and even up to health facility and community levels. These operational decisions have a major impact both on the efficiency with which services are delivered and their impact on health outcomes.