National Program for Family Planning and Primary Health Care in Pakistan

A country like Pakistan where there is deficiency of skilled and professional medical staff to reach every individual and provide health facilities. So, in these circumstances, importance and requirement of community health worker increased and that is why community health worker role is now deep rooted and well documented. Pakistan was in support of primary health care from 1978 after signing Declaration of Alma-Ata. Government of Pakistan started planning a Lady Health Worker Program in 1990. This program become Prime Minister’s Program for Family Planning and Primary Health Care in 1993 and launched in 1994 as a Federal Development Program by the Prime Minister of Pakistan, Benazir Bhutto.

Family Planning and Primary Health program’s purpose was to provide general health cover up to public of Pakistan. Then Prime minister’s vision and motivation led this program to one of the successful programs of the world that provide primary health facilities to almost more than 80 million people. These primary health services were provided at the door steps of public through community health worker.  Under this program, almost 100,000 lady health workers were trained. This best thing about this program was that locally literate ladies were chosen for training and were placed to those communities where they belonged. The lady health workers were trained to provide basic maternal and child health. The idea behind the deployment of lady health worker for community health was inspired from the concept of “barefoot doctors” which provide basic health care facilities in rural area of China during 1960s. Main purpose of this program was to build a bridge between rural community and health system. So, they can get benefit from health care system.

Health indicators for maternal and child health were a point of concern during 1970s and 80s. The reasons behind these poor indicators were investing more on tertiary care, neglecting primary health care, communication gap between community and national health care system and shortage of resources. So, National level program was need of time.

Trained lady health workers were placed to provide curative, preventive, promotion, education regarding family planning, maternal child health and rehabilitation services at their door steps.

Criteria for the selection of lady health workers:

Selection criteria for these lady health workers was very strict. Each lady health worker goes through the training of 15 months and then she will provide services to almost population of 1000, and about 150 homes. She needs to visit 5-7 homes per day. Their 15 months training was divided into two phases. Three months of classroom training in first phase and on-the-job training for 12 months in second phase. In their second phase of 12 months, they had three weeks for field work and one week for training. They also need to attend 15 days of refresher training each year. Selection of these workers was at following criteria:

• She should be married if possible
• Age should be minimum 18 years
• Locally resident
• Education at least middle pass
• Socially accepted or recommended

Primary health care services provision by lady health workers:

Lady health workers are trained to provide following primary health care services:

• Treatment of minor sickness
• Pregnant mother’s registration for antenatal care.
• Counseling of pregnant and lactating mothers about their issues.
• Screening on neonate for referral problems.
• Weight monitoring of the children which are under three years of age.
• Counseling regarding breast feeding
• Family planning counselling to married couples.
• Provide medicines like contraceptives, first aid to patients and clients.

Lady health workers are also trained to collect data for health management information systems like mapping of community, family register, community chart, mother and child health card and monthly report of lady health worker.

They are also responsible to provide medicine for curative purposes like Paracetamol Tabs, Chloroquine Tabs 150mg, Mebendazole Tabs, ORS, Cotrimoxazole Syp., Ferrous Fumerate + Folic Acid, Paracetamol Syp, Chloroquine Syp., Cotton Bandages, Benzyl Benzoate Lotion, Piperazine Syp, Polymyxin “B” Sulphate Eye Ointment (4 Gram), B. complex Syp Complex and Antiseptic Lotion. They also provide some non-drug items like Cotton Wool (250 Gram), Sticking Plaster 1” x 5m, Pencil Torch with Two Cells, Thermometer Clinical, Scissors, LHW Kit Bags and Salter Scale with Trouser.

Supervision method of Lady health workers:

Supervision of lady health worker is highly formulated and tiered in this program. These health workers are each attached to a public health clinic and are supervised by a supervisor on a monthly basis.  These Supervisors are supervised by the District Coordinator or Assistant District Coordinator of lady health worker program. Lady health workers are supervised in the community once in a month where the supervisor meet with client and lady health workers and evaluate their work according to standardized designed checklist and then plan of next month are made. Educational requirement for lady health worker’s supervisors is that they have completed the 12^th grade, but 66% of the supervisors have completed an even higher level of education. Each supervisor is responsible for 23 lady health workers according to this program.

Incentives and remuneration:

Salary of lady health workers is almost US$ 180 per month which is Rs. 27,881 approximately. These workers are not allowed to do any other paid job. But some of them also engaged in different paid activities to meet their expense. Because salary they received is the only source of family income and is a critical source of family support. Their salaries are paid monthly directly into their personal bank accounts, but mostly they did not receive their salaries on time. They also receive another incentive is in the form of money by selling contraceptives to their clients. In this program, 9% of patients reported that they paid for services to lady health workers, which are supposed to be free.

Another incentive is also offered to lady health workers in the form of professional advancement and promotions. So that they learn new skills and advance their career as a supervisor on completion of minimum education level which is intermediate to become a supervisor. Experience of one year of work experience as a lady health worker to become a lady health worker supervisor and two years of work experience as a lady health worker Supervisor to become an FPO.

Strengths of Program:

The good thing about this program was that the LHW program received sufficient political commitment, no matter which political party or military dictatorship was in power since 1994. This program received wide acknowledgement among all political and even also government sector. It has been supported both by administrative and financially without any interruption.

Recruitment of these workers by the community itself is main strength of this program. This program provides opportunity to the community to select appropriate lady which has sense of ownership and is fit for the job. It also empowers women by improving their social status and quality of life.

The program is one of the largest communities based which is providing its services mainly to the people of poor rural areas. It covers almost 60-70% of population which is in rural areas.

Program has good implementation strategies, well planned management and supervisory structures because it is ensuring regular and periodic monitoring and evaluation. Each lady health worker is supervised by lady health supervisor District Coordinator, Assistant District Coordinator, Provincial Field Programme Officer and Executive District Officer (Health). Each supervisor supervises 20 to 25 LHWs during the month and visits each lady health worker at least once a month in her health house and assess her work through records and physical verification in randomly selected households from the treatment register of the concern lady health worker.

It is comprehensive health care program. It includes both preventive and curative care which is provided at door step of population. Lady health workers provide a package of services including treatment for minor ailments, counselling regarding family planning, antenatal care referral to the first level care facilities when required, registration of pregnant mothers for antenatal care, ensuring clean and safe delivery, counselling of pregnant and lactating mothers, screening of neonates for problems if required referral, weight monitoring of the children under three years of age and provision of medicines, contraceptives to patients and clients.

This program also has good information management system called MIS (management information system) and is cost effective intervention. Through this system, information is collected from all PHC activities and logistics and is then transferred to district, provincial and federal levels. This information gathered through nine tools which not only helps lady health workers but also helps supervisors and managers to assess the performance of the respective lady health worker.

Weaknesses/challenges:

There are some weaknesses in this program. There are some issues at management in lower level. In some areas, people did not get or get poor quality of health care. In some areas, lady health workers do not work. Performance monitoring reports have revealed that there is lack of integration with BHUs and other health-related programs. This program should be inserted in wider health system.

Lady health workers are also facing problems regarding their salaries. There is delay in paying salaries to these workers. They have also problem of job security. Weak provision of equipment and medicines, poor referral system and poor quality of care in some areas are major problem and weakness of this program which should be addressed.

Conclusion:

It is one of the largest communities-based programs which is serving poor rural people across the country. It has gained a lot of trust from the community and is one of the successful programs but still It needs more political commitment, less political interference in management and coherence to achieve its goal.