Pakistan’s Iron Ladies

Provinces need to put more money and tech into this successful public health program

Pakistan’s Iron Ladies
There is an army in this country you may not know about. Over 100,000 strong, it is embedded in villages and informal settlements from Karachi to Gilgit. Its educated and well-trained soldiers—all women—are on the frontlines of our country’s most important battle.

These soldiers, otherwise known as Lady Health Workers, are a part of one of the largest community health worker programs in the world. While much of Pakistan’s urban elite is unaware of their existence, public health researchers have been paying close attention to their work.

Notably, a 2014 working paper co-published by the Harvard School of Public Health (Lady Health Workers in Pakistan: Improving Access to Health Care for Rural Women and Families, May 2014), called the program “a springboard for female empowerment”. It reckoned that the program “offers important lessons and may present a replicable Community Health Worker model to the global community”. Peers for Progress (affiliated with the American Academy of Family Physicians Foundation) describes the program as having “made a remarkable impact on the health of women and children in Pakistan”. Publications by the WHO, UNDP, and the Pakistan Medical Association, have echoed these findings.

Whenever someone credible points to anything in Pakistan as a potential model for other countries to follow, it is worth sitting up and taking notice. Who are these women? What do they do? What impact have they had? And, of course, with Pakistan’s health outcomes still far from what we should expect, how can the state better leverage this program to improve the health, nutrition, and reproductive decisions of our poorest and most vulnerable? Given what we know about the feedback loop between ill health and poverty, answering this question is not just a moral imperative, but an economic necessity.

Who are these women, and what do they do?

Launched in 1994, by the Pakistan Peoples Party-led federal government, the Lady Health Worker (LHW) program is arguably one of Benazir Bhutto’s most important legacies. The idea behind the program (not be confused with earlier village midwife programs, referred to as Lady Health Visitors) was to raise a cadre of women around the country to help improve maternal and child health, and facilitate family planning, in their own communities.

The target communities included all rural, and some low-income urban areas. To be an LHW, one had to have eight years of schooling, and be recommended by the community, following which prospective LHWs would complete a 15-month training program (3 months classroom, 12 months practical) covering the basics of primary health care.

The modus operandi of the newly trained LHW has remained broadly the same since the program’s inception—primary health care delivered at the doorstep of poor Pakistanis. What was originally thought of by many as far too audacious for a patriarchal society, quickly gained the trust of rural communities across the country (though LHWs routinely report that harassment is common).

How much it costs


of Pakistan's national income or just about $200 million in salaries a year is what Pakistan pays LHWs. They get under Rs17,000 a month

Each LHW is responsible for approximately 200 households within her community, each of whom she visits once a month, inquiring about health problems, giving family planning advice, dispensing oral and barrier contraceptives, iron and folic acid supplements (to combat anaemia in reproductive age women), and medication for worms.

The lengthy list of assigned tasks includes promoting the use of government health facilities (for childbirth in particular), basic hygiene, exclusive breastfeeding, the use of iodized salt, and the treatment of common ailments. Priority areas change in line with governmental concerns, which also lead to the addition of new tasks, such as, for example, participating in immunization drives, an activity with more serious risks to life and limb than many LHWs may have bargained for.

The program initially grew rapidly from around 30,000 workers to around 100,000 by 2005 after which the numbers stagnated. There are around as many lady health workers today as there were ten years ago (maintaining the cadre is now a provincial responsibility). Ironically, a 2012 Supreme Court decision forcing the government to “regularize” the services of LHWs, making them government servants eligible for pensions, is cited by health sector insiders I spoke to as a major reason for the reluctance of provincial governments to hire more people into the program.

For their troubles, LHWs, most of whom are the primary breadwinner of their families, are paid just under 17,000 rupees a month.  Back of the envelope that’s about $200 million a year in salaries, nationwide, around 0.07% of Pakistan’s national income.

What impact have they had?

The impact of the program on public health was widely studied while it was still in federal hands but less so since health was devolved to the provinces. The most in-depth examinations have been a series of donor-funded (CIDA, DFID, WB) and validated evaluations conducted by Oxford Policy Management, a development consulting firm.

Findings from their last (2009) evaluation included: Households served by LHW were eleven percentage points more likely to use modern family planning methods than unserved households; fifteen percentage points more likely to have received a health check-up within 24 hours of a delivery, and fifteen percentage points more likely to have their children fully immunized by the age of three.

There are some important caveats to these numbers (which can be found online in the OPM report’s quantitative section). Nonetheless, multiplied across millions of covered households each year, these gains translate into huge numbers of people with smaller family sizes, less serious health problems, and higher life-long earning potential.

Other indicators, such as exclusive breastfeeding rates, and diarrhoea incidence showed far more limited impact. But, interestingly, higher performing LHWs were found to have substantial influence on these areas as well. As the 2014 Harvard SPH paper put it, the program has “successfully accelerated Pakistan’s progress towards achieving universal health care and the health and poverty related MDGs, and has also contributed to closing Pakistan’s gender equity gap”. Impressive stuff.

The progress being referred to includes a reduction in the under-5 death rate (the probability of a newborn dying within five years of birth) per 1,000 births from 131 in 1993 to 79 in 2017 (WB, World Development Indicators) and halving of maternal mortality rates (WHO data) over the same period.

Of course, Lady Health Workers have not been the only, or even the main, factor in this progress, which happened over a period that coincided with increasing education, falling poverty rates, medical science advances, and other local health-care delivery improvements. And of course, these numbers are still very high relative to comparable countries, while other areas, such as stunting rates, have shown no progress at all. Nonetheless, the weight of the evidence supports the indispensable role Pakistan’s iron ladies have played in improving public health in the country.
One worker, covering a low-income neighbourhood in Lahore told me she and her colleagues are given 100 condoms a month to distribute amongst 300 households. That's some grim math

How can we build on their success?

As one health sector consultant in Punjab characterized it, “the LHW program is the backbone of the health department here. It is really the only way we can communicate with the poorest segment of the population about health and influence their behaviour; there’s no real penetration of media or advertising...”

To the extent that each provincial government wants to further improve public health in our greatest current problem areas, like malnutrition, stunting, and population control (all three of which require behavioural changes), they will have to use the biggest tool in their kit: the lady health workers program.

Ahead of elections, with focus on health and nutrition growing, the contending political parties would do well to highlight how they plan on doing so.

They should consider announcing plans to leverage the program with technology. Tablet- and phone-based apps could be used to help drive LHW performance, disseminate information and low-cost training (including elements of behavioural science) to the LHWs, and collect health data. It may be worthwhile to adopt lessons from the use of technology in the public education sector. In Punjab, for example, a team of monitors with GPS-equipped tablets surveys schools, reporting on facilities, teacher attendance, and even student learning. The results have been the subject of international attention and praise. Imagine what could be done with real-time health data being collected and analysed across an entire province. Imagine the possibility of adaptive, tablet-delivered training delivered instantly. Think of the impact of technology-enabled supervision on the performance of some of the less conscientious lady health workers (of which, to be sure, there are some).

Encouragingly, the Punjab and Sindh governments have already begun taking very small steps in this direction with the LHW program. Their early learnings should inform what one hopes will be bold plans for the future, that should be replicated in other provinces. It is simply not acceptable anymore for 100,000 women to be going door-to-door collecting data in worn registers.

Concrete plans to improve the effectiveness of the program, and use it to tackle new health challenges, will have to be backed with monetary commitments, and more hiring. Estimates of the number of LHWs required across the country were as high as 150,000, 18 years ago. With the number of workers not growing, the coverage population of existing workers has stealthily expanded, making it even harder to cover the prescribed tasks. This was corroborated by LHWs I spoke to.

More money to the program must include more money for supplies. Nutrition interventions to combat stunting and wasting, in particular, will require this. Meanwhile, funding is running short as it is. LHWs already speak of delayed and missing salary payments. Reports, both academic, and anecdotal, of material shortages, abound. One worker, covering a low-income neighbourhood in Lahore told me she and her colleagues are given 100 condoms a month to distribute amongst 300 households. That’s some grim math.

So, when the parties talk, as they likely will, about increasing health spending in the provinces, they should be clear about how much of it will be spent on the LHW program, and what it will be used for. Because while Pakistan continues to lag behind its income peers in many key metrics, such as infant and maternal mortality rates, and the prevalence of stunting and wasting, Pakistan’s iron ladies can help make things better.

The writer is a Lahore-based columnist. He has served as a director at a major European investment bank and worked as a strategy consultant at a leading global consulting firm, where he participated in an extensive social sector delivery initiative led by the GoP. The views expressed are entirely his own. @assadahmad