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The National Programme for Family Planning & Primary Health Care - an overview
The National Programme for Family Planning and Primary Health Care, also known as the Lady Health Workers Programme (LHWP) was launched in 1994 by the Government of Pakistan with the objective of reducing poverty through providing essential primary health care services to communities and improving national health indicators. The Programme objectives contribute to the overall health sector goals of improvement in maternal, newborn & child health; provision of family planning services; and integration of other vertical health promotion programmes. This country wide initiative with community participation constitutes the main thrust of the extension of outreach health services to the rural population and urban slum communities through deployment of over 100,000 Lady Health Workers (LHWs) and covers more than 65% of the target population. The Programme contributes directly to MDG goals number 1, 4, 5 & 6 and indirectly to goal number 3 & 7. The National Programme for Family Planning and Primary Health Care is funded by the Government of Pakistan. International partners offer support in selected domains in the form of technical assistance, trainings or emergency relief.
Conceptual framework
As the largest community based initiative in the country, ‘the Lady Health Worker model’ is built around the concept of providing easy and continued access to primary health care services at the door steps of the community through women volunteers from the community. The Programme however adopted the model of paying a ‘stipend’ to the community workers (Lady Health Workers) in order to keep them motivated and for retaining trained human resource. The conceived role of the Lady Health Workers (LHWs) includes helping communities identifying and addressing their health needs on their own as well as serving as a link between communities and the health system. They bridge the gap between the health facility and communities, through provision of quality integrated primary health care services.
Recruitment and trainings
The Lady Health Workers (LHWs) are recruited through a well defined process according to a strict selection criteria – a) being a local resident; b) having completed at least grade 8; c) preferably married; d) between 18-45 years of age; e) and being acceptable to the community. Recruitment is followed by training which includes 3 months of structured class room sessions and a second 12 month phase of supervised field work. During the second phase the LHWs return to the class-room for one week in every four weeks for formal sessions. The entire training is delivered at the First Level of Care Facility (FLCF) by facility staff, which includes a Medical Officer, a Lady Health Visitor (skilled birth attendant) and a Health Technician. This pre-service training of Lady Health Workers is complemented by regular one day “continued education sessions” each month and 15 days of “refresher training” on various health issues every year.
Scope of work
The catchment of each Lady Health Worker includes approximately a population of 1000 persons or 150 homes. The LHWs usually performs their job through regular home visits of 5- 7 households a day. Their own residences are designated as 'Health House' to make the community aware of their presence and access services in case of need or emergency. Their core responsibility is advocacy, health education and creating awareness for promoting community health. Their scope of work includes over 20 tasks, ranging from counseling on various health issues, provision of family planning services, antenatal referrals, immunization services, basic curative care and supporting community mobilization. The working hours of LHWs are flexible and they do not report anywhere for duty. They however visit the attached health facility (FLCF) once a month for continued education sessions, collecting supplies which are replenished on a monthly basis and for submitting monthly reports prepared by them. On an average, the LHWs work about five hours each day and are paid a stipend. The services of the Lady Health Workers, including the medicines and family planning commodities they offers, are provided free of cost to the community.
Supervision and monitoring
The quality of care delivered to the community is maintained through a well established supportive supervisory network right from the community to the federal level. The monitoring and supervisory cadres include Lady Health Supervisors (1 LHS supervises 20-25 LHWs), Field Program Officers (FPOs) and a well integrated management setup at the District, Provincial and Federal level. The Lady Health Supervisors (LHSs) are recruited from the community against a selection criterion similar to the LHWs except that their minimum education requirement is having passed grade 12. Their training model is very similar to that of the LHWs. All supervisory cadres are provided with Programme vehicles to facilitate field monitoring according to a planned schedule. Monthly meetings of LHSs and FPOs are held at the district level for sharing of reports and feedback. Quarterly district and provincial review meetings are held and are attended by all Programme levels (district, provincial, federal) for sharing updated information, addressing issues and for future planning and guidelines.
Programme coverage
The Programme began with strength of a little over 30,000 LHWs and over the years has expanded to a strength of over a 100,000 LHWs currently deployed across all provinces and regions of the country. The Programme coverage extends to more than 65% of the target population which is the rural population and communities living in urban slums across the entire country. The Programme operates in all 135 districts of the country. However within certain districts there are still hard to reach areas where the Programme does not exist. The main constraints for absent Programme coverage are non-functional health facilities or low female literacy with women not meeting the selection criteria for recruitment as LHWs and LHSs.
In context of the health system
The Programme is designed as an extension of the district health system and is implemented in close collaboration and coordination with other national primary health care programmes to ensure efficient and effective utilization of public resources. Operational implementation is carried out by the provincial health departments and district health offices with maximum authority delegated to the FLCF level. The Programme provides an established network of health care delivery channels within the community and serves as a medium through which projects are piloted and later replicated for integration into the health system. LHWs are essentially the nexus around whom all primary health care initiatives converge for service delivery to the community. Therefore in addition to their stipulated tasks, an important role of the Lady Health Workers is to serve as a conduit for implementation of almost all national and international community health initiatives.
Programme Impact
Health impact: The Lady Health Workers Programme has been successively evaluated externally and the most recent was the 4th Third Party Evaluation (2008-09) carried out by the Oxford Policy Management, UK. The evaluation report stated that “LHWs play a substantial role in preventive and promotive care and in delivering some of the basic curative care in their communities, as well as providing a link to emergency and referral care”. It also concluded that “LHW Programme has significant impact on the population it serves” and “it has maintained the impact despite significant expansion of the Programme” (Oxford Policy Management: 2009)
Gender impact: The impact of Lady Health Workers on the rural social fabric is worth recognition. Personally they have emerged as symbols of women empowerment against the odds of tradition and rigid religious norms. Within the community they have rendered worth and value to the status and work of women. In the back drop of strong gender bias the LHWs have transpired into role-models for younger women in their communities. Through them other women have been empowered to take decisions regarding their health and family. The contribution of LHWs in uplifting the image and plight of rural women despite cultural constraints is note-worthy. According to the external evaluation report 2009 “the Programme is having a positive affect on the well-being and empowerment of women it employs. LHWs are relatively more empowered compared with other working women.” (Oxford Policy Management: 2009)
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