Our unsung heroines

Our frontline health workers including Lady Health Workers (LHWs), Community Midwives (CMWs) and Vaccinators are the real heroes in Pakistan’s fight to prevent child and maternal mortality in the country to be able to achieve Millennium Development Goals (MDGs) 4 & 5. MDG 4 is about two third reduction in child mortality and MDG 5 is about three quarters reduction in maternal mortality ratio by 2015. The progress towards achieving MDGs remains a challenge and an elusive dream for Pakistan where 352,400 children under-5 die of preventable causes every year. The national under 5 mortality rate is 87 per 1000 live births and the maternal mortality rate is at an alarming 276 deaths per one 100,000 live births. There is a need to accelerate the efforts to be able achieve MDGs 4&5.

The LHWs and vaccinators are not only playing a leading role in preventing thousands of preventable child deaths but are also our frontline force against the ongoing fight in the country for the eradication of polio. Unfortunately however, in the recent past we not only witnessed targeting of the LHWs and vaccinators by the terrorists but also a cold shoulder by the government towards resolving their issues.

The last approved PC-1 of LHW Programme has targeted the expansion of LHWs from existing number to 130,000 by 2015 with a focus on expansion to marginalize and disadvantageous uncovered areas. The 18^th Amendment has implicated the expansion by bringing a standstill situation to the programme owing to lack of funds for meeting the operational cost of existing LHWs and barring the expansion. Lately, through judicial intervention the LHWs have been regularized throughout the country and their rewards have also been increased. However, we still see LHWs on the streets demanding documentation of their regularization and implementation of the decision in letter and spirit by the federal and provincial governments. 

Lack of frontline line health workers such as LHWs and Community Midwives is one of the major reasons of Pakistan’s slow progress towards achieving MDG 4 & 5 as currently there are 97,639 LHWs and 3,843 Lady Health Supervisors (LHSs) in the country covering only 60% of the population against the proposed target to increase this number to 130,000 by 2015. Following Supreme Court of Pakistan’s intervention, the previous government regularized the services of LHWs, LHSs and other staff of the Family Planning & Primary Health Care Programme with Federal Government’s full funding for this programme up to 7^th NFC Award (FY-2015) as already decided by the Council of Common Interests.

While regularizing the LHWs, the previous federal government included a stringent condition; the posts that may become vacant as a result of resignation, losing jobs or otherwise shall stand abolished for the purpose of federal funding and new recruitment w.e.f. 1-7-2011 will be financed by the provincial governments. Likewise, any new creation of posts/appointments or future need will be financed by the provinces from their own budget/resources. This condition resulted in decrease in the number of LHWs instead of increasing their number i.e. in Punjab the number LHWs decreased from 49,000 to 47,300 and similarly in other provinces.

The incumbent federal government should intervene and reverse this decision by allowing the provincial governments to fill the vacant position i.e. 1,700 positions in Punjab to be filled immediately. Secondly, coordinate with the provinces and support them in recruiting more LHWs and making budgetary allocations for necessary supplies to reach to the uncovered areas and help Pakistan progress towards achieving MDGs 4 & 5. Similarly, the provincial governments should also take responsibility and start allocating resources for increase in the number of LHWs, CMWs and vaccinators in the respective provinces to be able to reach out to 100% population and achieve mother and child health related targets.

According to the findings of research studies by Professor Dr. Zulfiqar A Bhutta and others, in many countries, community health workers are now offering a wide menu of services to communities in different types of challenged settings. Their services include conducting deliveries, conducting counseling and health education, immunization, management of childhood illnesses at community level such as diarrhea, malaria and pneumonia and malnutrition. The community health workers’ services have led to decrease in child and maternal mortality in different countries.

The successive governments since 1993 have relied on LHW Programme for the delivery of health services to the far flung areas. The key policy instruments of development in Pakistan over this time period have included LHW Programme as a primary area of investment for meeting health challenges. Besides, non-governmental initiatives such bilateral projects, UN initiatives for child health etc have also heavily relied on LHW Programme for delivery of services targeting the achievement of MDGs.

The menu of services of LHWs include 20 key tasks related to maternal, newborn and child health care and the health indicators in LHW covered areas are significantly better than the national averages. Research has proved that the coverage of some key interventions for maternal and child health such as fully immunized children, knowledge of mothers about preparation of ORS, antenatal consultations, measures of exclusive breastfeeding  have improved in LHW covered areas. The children under 3 years of age in LHW covered areas are 15 percentage points likely to be fully immunized as compared to areas not covered by LHWs. When analyzed LHWs performance for difference in poor and rich, it has been found that the effects were larger for poorer households especially in maternal and neonatal health practices, immunization and growth monitoring according to Oxford Policy Management findings of 2009.

There are issues around LHWs coverage, remuneration and operational aspects of their programme. Currently LHWs cover only 60% of the population, nearly 25% of LHWs are low performing, there are delays in the salaries disbursements, the stock outs of medicines along with non availability and/or dysfunctional equipment is a continuous problem, the supporting referral system is not helpful due to staff absenteeism and other issues at the referral facilities.

It is imperative that LHWs coverage is expanded to un-served rural poor populations and urban slums and that will be possible only if their number is increased and all the current vacant positions are filled immediately. Similarly, it is important to ensure that they are provided with the required stock of medicines and equipment, their terms of reference are reviewed and routine immunization is formally incorporated; they are trained to be able to provide mothers with skilled support to improve child feeding practices, including breastfeeding and to contribute in maternal and newborn care. The monitoring mechanisms should be strengthened as well to ensure effective utilization of this vital human resource.

It is crucial that the provincial governments take a leadership role, with the support of the federal government, and strengthen the Programme at the provincial levels. The Programme should be structured in such a way that the staff is satisfied and are able to concentrate on performing their job which is critical for Pakistan’s acceleration of progress towards achieving MDGs.

This blog also published as an op-ed in The News on Sunday on October 13, 2013 http://jang.com.pk/thenews/oct2013-weekly/nos-13-10-2013/pol1.htm#4