Pakistan's Lady Health Workers "Best in the World"

[Riaz Haq]

“It’s one of the best community-based health systems in the world,” said Dr. Donald Thea, a Boston University researcher about Pakistan's Lady Health Workers Program. Thea is one of the authors of a recent Lancet study on child pneumonia treatment in Pakistan. He talked with the New York Times about the study.

Published in British medical journal "The Lancet" this month, the study followed 1,857 children who were treated at home with oral amoxicillin for five days and 1,354 children in a control group who were given standard care: one dose of oral cotrimoxazole and instructions to go to the nearest hospital or clinic. The home-treated group had only a 9 percent treatment-failure rate, while the control group children failed to improve 18 percent of the time.

Launched in 1994 by former Prime Minister Benazir Bhutto's government, Pakistan’s Lady Health Workers’ program has trained over 100,000 women to provide community health services in rural areas. The program website introduces it as follows: "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."

A recent comprehensive review of the program found that as compared to communities not served by the LHWs, the served households were 11% more likely to use modern family planning methods, 13% were more likely to have had a tetanus toxoid vaccination, 15% more were likely to have received a medical check-up within 24 hours of a birth, and 15% more were likely to have immunized children below three years. The improvements in health indicators among the populations covered by the LHWs were not entirely attributable to the program alone; researchers noted that other positive changes such as economic growth, increased provision of health services and better education services helped to enhance the impact. While the program had managed to sustain its impact despite its large expansion, evaluators found that serious weaknesses in the provision of supplies, and equipment and referral services need to be urgently addressed.

The program is now a major employer of women in the non-agricultural formal sector in rural areas, and is being more than doubled in size if budget allocations can be sustained. If universal coverage is achieved, every community in the country will have at least one lady health worker, one working woman and potential leader, who could serve as a catalyst for positive change for women in her community. The health officials say that unlike the mid-1990s when it was difficult to recruit women because of the minimum 8th grade education requirement, now there are large numbers of women who meet the requirement lining up for interviews in spite of low stipend of just Rs. 7000 per month.

Private sector is also helping the LHW program. Mobile communications service provider Mobilink has recently partnered up with the United Nations Population Fund (UNFPA), Pakistan's Ministry of Health (MoH) and GSMA Development Fund in an innovative pilot project which offers low cost mobile handsets and shared access to voice (PCOs) to LHWs in remote parts of the country. Mobilink hopes to bridge the communication gap between the LHW and their ability to access emergency health care and to help the worker earn extra income through the Mobilink PCO (Public Call Office).

Due to economic downturn and security challenges in several conflict areas since 2008, Pakistan's chances of achieving its Millennium Development Goals (MDGs) by 2015 appear to be slim. However, significant timely expansion in the LHW program and making it more effective can still help Pakistan get close to its MDGs on important health indicators like the infant mortality rate (IMR) and the maternal mortality rate (MMR).

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[Riaz Haq]

Here's Daily Times on more midwives for Pakistan:

Speakers at the second annual conference on Maternal and Newborn Health Programme have stressed the importance of research-based evidence to improve policies and practices related to maternal and newborn health in Pakistan.

The conference was held on Thursday, with the theme ‘Bridging the Gap – Evidence for Policy and Practice’. Findings and lessons from projects funded by Research & Advocacy Fund (RAF) were presented. Sessions focussed on the cost and financing of maternal and newborn health in Pakistan, socio-economic and cultural factors affecting maternal and newborn health and engaging with civil society to improve health outcomes.

Delegates from both the public and private sector, including provincial secretaries and director generals of health and heads of various national and international NGOs attended the event.

Planning Commission of Pakistan’s deputy chairperson, Dr. Nadeem ul Haq hoped the commission will learn from the research findings from RAF work.

Peter Upton, Director British Council, Desmond Whyms, Senior Health Advisor UKaid, Andrew Mackee, Acting Counsellor Development Cooperation AusAID and Sarah Hall, Programme Manager RAF also addressed the audience, stressing the respective commitments of their organisations to remain engaged in improving Pakistan’s health outcomes. The speakers highlighted the purpose of RAF, and stressed the need to share knowledge, information and strengthen collaboration between national, provincial and local public and private stakeholders to work together to improve maternal and newborn health in Pakistan.

“Women and children are the UK’s number one health priority in Pakistan” said Desmond Whyms. He claimed that by 2015, UK aid would have funded the training and deployment of 12,000 community based midwives, helped prevent the death of 3,600 mothers, delivered 350,000 more babies in hospitals and provided full immunisation for 280,000 children.

http://www.dailytimes.com.pk/default.asp?page=2013\03\22\story_22-3-2013_pg11_3

[Riaz Haq]

Here's a story about a telehealth facility for women in Karachi:

Karachi: Pakistan’s largest city and commercial centre, Karachi, is a city of extremes where the richest live alongside the country’s poorest. Perfectly coiffed women with foreign degrees and fancy handbags tour around the city’s designer malls. At the other end of the spectrum, a range of hurdles leave women from the poorest sections of society struggling to access basic services, particularly healthcare.
But a recently launched telehealth service is hoping to change that by giving women in Karachi, Pakistan’s largest city with a population of around 18 million, access to basic health advice for free from a mobile phone.
“This is a big opportunity to improve access to woman in urban areas who have no access to basic healthcare and information, particularly during pregnancy,” says Zahid Ali Fahim, head of the telehealth service run by the Aman Foundation, a Pakistan-based non-governmental organisation. Dr Fahim oversees the 26-seat call centre that has been working around the clock for the past 18 months.
According to the World Health Organisation’s Global Health Observatory report, 40 per cent of premature deaths in adults in Pakistan would have been preventable through early intervention. Though there is no official WHO breakdown by gender, experts say a significant portion of those premature deaths are women. Distance to hospitals and clinics, the cost of transport, and low levels of trust in government-run services leaves men and women unable to seek the medical help they may need.
A strict social code for many women presents an additional obstacle. Low literacy rates — 57 per cent of women are illiterate in Pakistan compared with 26 per cent of men — and a lack of basic health knowledge compound the problem.
When women are able to travel to a clinic or hospital, they are usually accompanied by a male relative, leaving many unwilling — or unable — to explain their medical problem to the doctor.
“Women don’t want to get healthcare services without their [male relative] presence,” explains Dr Fahim, “But she cannot say anything when she goes to the facilities. The head of the family does all the talking.”...

http://gulfnews.com/news/world/pakistan/pakistan-women-can-now-dial...

[Riaz Haq]

Here's an excerpt of a Dawn Op Ed on declining fertility rates in Pakistan:

Getting down to two children per family may seem an elusive target, however, Pakistanis have made huge dents in the alarmingly high fertility rates, despite the widespread opposition to family planning. Since 1988, the fertility rate in Pakistan has declined from 6.2 births per woman to 3.5 in 2009. In a country where the religious and other conservatives oppose all forms of family planning, a decline of 44 per cent in fertility rate is nothing short of a miracle.

A recent paper explores the impact of family planning programs in Pakistan. The paper uses data from the 2006-07 Pakistan Demographic and Health Survey, which interviewed 10, 023 ever-married women between the ages of 15 and 49 years. The survey revealed that only 30 per cent women used contraceptives in Pakistan. Though the paper in its current draft has several shortcomings, yet it still offers several insights into what contributes to high fertility and what the effective strategies are to check high fertility rates in Pakistan.

The survey revealed that the use of contraceptives did not have any significant impact for women who had given birth to six or more children. While 24 per cent women who were not using any contraceptives reported six or more births, 37 per cent of those who used contraceptives reported six or more births. At the same time, 27 per cent of women who were not visited by the family planning staff reported six or more births compared with 22 per cent of women who had a visit with the family planning staff.

Meanwhile, demographic and socio-economic factors reported strong correlation with the fertility outcomes. Women who were at least 19 years old at marriage were much less likely to have four or more births than those who were younger at the time of marriage. Similarly, those who gave birth before they turned 19 were much more likely to have four or more births.

Education also reported strong correlation with fertility outcomes. Consider that 58 per cent of illiterate women reported four or more births compared to 21 per cent of those who were highly educated. Similarly, 60 per cent of the women married to illiterate men reported four or more births compared to 39 per cent of the women married to highly educated men. The survey revealed that literacy among women mattered more for reducing fertility rates than literacy among their husbands.

The underlying variable that defines literacy and the prevalence of contraceptives in Pakistan is the economic status of the households. The survey revealed that 32 per cent of women from poor households reported six or more births compared to 21 per cent of those who were from affluent households.

The above results suggest that family planning efforts in Pakistan are likely to succeed if the focus is on educating young women. Educated young women are likely to get married later and will have fewer children. This is also supported by a comprehensive study by the World Bank in which Andaleeb Alam and others observed that cash transfer programs in Punjab to support female education resulted in a nine percentage point increase in female enrollment. At the same time, the authors found that those girls who participated in the program delayed their marriage and had fewer births by the time they turned 19.

http://www.dawn.com/news/1038948/keeping-pakistans-high-fertility-i...

[Riaz Haq]

Here are some findings of UNICEF's Child Survival Report 2013:

1. Pakistan's infant mortality rate is ranked 26th worst in the world.

2. Pakistan remains high though it has been coming down from 138 per 100,000 in 1990 to 112 in 2000 to 86 in 2012.

3. Pakistan is among the five countries (India 22%, Nigeria 13%, Democratic Republic of Congo 6%, Pakistan 6% and China 4% in that order) across the world where half of all under-five deaths occur.

4. The report recommends exclusively breastfeeding all newborns till six months of age, immunizing children and newborns with all recommended vaccines, and eliminating all harmful traditions and violence against children. To ensure children grow up in a safe and protective environment. Besides this feed children with proper nutritional foods and micronutrient supplements, where available, and de-worm children; give oral rehydration salts (ORS) and daily zinc supplements for 10-14 days to all children suffering from diarrhea.

http://www.unicef.org/publications/files/APR_Progress_Report_2013_9...

[Riaz Haq]

Antenatal and postnatal care for women in rural Pakistan has improved dramatically, thanks in part to the work of women like Shagufta Shahzadi, a skilled birth attendant trained under a UNICEF-supported programme.

KASUR DISTRICT, Pakistan, 3 December 2014 – “My biggest pleasure is to see that the mother and child are both healthy after the delivery,” says Shagufta Shahzadi, 30, a skilled birth attendant (SBA) who lives and works in Nandanpura village, Kasur district, in Pakistan’s Punjab province. 

“There is a huge difference between services provided by a trained birth attendant and an untrained traditional midwife. A skilled person knows how to prevent and deal with complications during pregnancy, at the time of delivery and delivering postnatal care for mother and child.”

A day’s work for Shagufta could include delivering a baby, advising pregnant women on prenatal care, walking to the neighbouring village to provide postnatal care to a mother and the newborn. She takes a lot of pride in her work and feels a sense of achievement in the fact that due to her services, there hasn’t been a case of a pregnant mother or newborn death in her area over the last year.

Looking back at the struggle she had to make throughout her life, Shagufta recalls, “I was two months old when my father passed away. My mother raised me and my sister with the little money she earned by stitching cloths. Her resources were meagre, yet she made sure that we both completed our matriculation. Thereafter, we completed our respective trainings. My sister became a lady health worker, and I became a skilled birth attendant.”

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“Due to the positive results of this programme, the Government of Pakistan has scaled up the initiative across the country,” says Dr, Tahir Manzoor, Health Specialist at UNICEF Pakistan. “In Punjab province, more than 5,000 women have been trained and are performing valuable services within their own communities. We can already see the positive impact of their services and are certain that it will improve the scenario of mortality and morbidity for mothers and new born children in Pakistan over the next few years.”

Shagufta believes that ensuring health and safety for mother and child is imperative.

“If mothers and children are healthy, the entire society will be healthy. The future generations will be healthy," she says. "We must try to save lives, as life is precious, and you only get it once.” 


http://www.unicef.org/infobycountry/pakistan_78038.html

[Riaz Haq]

How #Pakistan’s National Health Insurance Program Will Work http://on.wsj.com/1VrDRpC via @WSJIndia

Pakistan’s government launched a national health insurance program for its poorest households Thursday, marking the start of the most-ambitious public health project in the country’s history.

The Prime Minister’s National Health Program will from Thursday cover families that make less than $2 a day through a gradual rollout. In the first phase, over 3 million families will get health insurance in 23 districts, with the ultimate aim to cover 22 million households across the country, officials said.

“This is another step towards the welfare state that we promised to create when we came into power,”said Pakistani Prime Minister Nawaz Sharif.

The Pakistani government already subsidizes health care to varying degrees in public hospitals, but officials acknowledge these facilities are unable to handle the patient load or achieve public health targets.

The government said earlier this year that it wouldn’t be able to meet the United Nation’s targets for child and maternal mortality rates that formed part of the Millennium Development Goals, which had a deadline of 2015. Critics have blamed Pakistan’s low health spending and inadequate management as key factors in the poor health provision. Between July 2014 and March 2015, Pakistan spent just 0.42% of its GDP on health. The U.S. government spends about 8.3% of GDP on healthcare.

The new insurance program will cover treatment at both public and private hospitals. Private hospitals that sign up will then be offered loans on easy terms to upgrade their facilities, officials said, without providing further details about interest rates and conditions.

Saira Afzal Tarar, minister of state for health Services, regulations and coordination, said most Pakistanis pay out of pocket for treatment. “There is treatment at government-run hospitals, but there are long lines. Those who don’t have a recommendation have to wait months for treatment,” Ms. Tarar said at the launch ceremony in Islamabad. “With this [health insurance] card, you’ll be able to go to the hospitals where you weren’t allowed to even go to the front door. Now, you’ll be treated there with dignity and respect.” Ms. Tarar said.

The national health program, with an initial funding of 9 billion Pakistani rupees ($86 million) will pay for the treatment of the types of illnesses identified by the government as critical: heart disease, diabetes and related illnesses, cancer, kidney and liver diseases, complications from infections like HIV and Hepatitis, road accidents, and burn injuries. Officials said coverage can be extended to other conditions considered life-threatening.

The government said Thursday that the program will be run in partnership with provincial governments, which will share the financial burden. Beneficiaries will receive insurance cards, after selection from a database of low-income Pakistanis set up in 2008 for a separate cash support program.

The coverage includes 50,000 rupees for general treatment, and 300,000 rupees for serious illnesses. Mr. Sharif said on Thursday that the government is making arrangements for an emergency fund that would extend coverage to 600,000 rupees for cases that require longer treatment.

Officials on Thursday didn’t provide specific timelines for the rollout of the next phase, which is expected to cover another 3.3 million households. The finance ministry said earlier this year that the program aims to cover 22 million families.

The finance ministry, quoting World Bank data and 2008 population estimates, said last year that if living on $2 a day is taken as the poverty line, over 60% of the population would fall in that category.

[Riaz Haq]

How #Pakistan’s National Health Insurance Program Will Work http://on.wsj.com/1VrDRpC via @WSJIndia

Pakistan’s government launched a national health insurance program for its poorest households Thursday, marking the start of the most-ambitious public health project in the country’s history.

The Prime Minister’s National Health Program will from Thursday cover families that make less than $2 a day through a gradual rollout. In the first phase, over 3 million families will get health insurance in 23 districts, with the ultimate aim to cover 22 million households across the country, officials said.

“This is another step towards the welfare state that we promised to create when we came into power,”said Pakistani Prime Minister Nawaz Sharif.

The Pakistani government already subsidizes health care to varying degrees in public hospitals, but officials acknowledge these facilities are unable to handle the patient load or achieve public health targets.

The government said earlier this year that it wouldn’t be able to meet the United Nation’s targets for child and maternal mortality rates that formed part of the Millennium Development Goals, which had a deadline of 2015. Critics have blamed Pakistan’s low health spending and inadequate management as key factors in the poor health provision. Between July 2014 and March 2015, Pakistan spent just 0.42% of its GDP on health. The U.S. government spends about 8.3% of GDP on healthcare.

The new insurance program will cover treatment at both public and private hospitals. Private hospitals that sign up will then be offered loans on easy terms to upgrade their facilities, officials said, without providing further details about interest rates and conditions.

Saira Afzal Tarar, minister of state for health Services, regulations and coordination, said most Pakistanis pay out of pocket for treatment. “There is treatment at government-run hospitals, but there are long lines. Those who don’t have a recommendation have to wait months for treatment,” Ms. Tarar said at the launch ceremony in Islamabad. “With this [health insurance] card, you’ll be able to go to the hospitals where you weren’t allowed to even go to the front door. Now, you’ll be treated there with dignity and respect.” Ms. Tarar said.

The national health program, with an initial funding of 9 billion Pakistani rupees ($86 million) will pay for the treatment of the types of illnesses identified by the government as critical: heart disease, diabetes and related illnesses, cancer, kidney and liver diseases, complications from infections like HIV and Hepatitis, road accidents, and burn injuries. Officials said coverage can be extended to other conditions considered life-threatening.

The government said Thursday that the program will be run in partnership with provincial governments, which will share the financial burden. Beneficiaries will receive insurance cards, after selection from a database of low-income Pakistanis set up in 2008 for a separate cash support program.

The coverage includes 50,000 rupees for general treatment, and 300,000 rupees for serious illnesses. Mr. Sharif said on Thursday that the government is making arrangements for an emergency fund that would extend coverage to 600,000 rupees for cases that require longer treatment.

Officials on Thursday didn’t provide specific timelines for the rollout of the next phase, which is expected to cover another 3.3 million households. The finance ministry said earlier this year that the program aims to cover 22 million families.

The finance ministry, quoting World Bank data and 2008 population estimates, said last year that if living on $2 a day is taken as the poverty line, over 60% of the population would fall in that category.

[Riaz Haq]

The 'Avon ladies' of #Pakistan selling contraception door to door. #BirthControl #Pills

http://www.theguardian.com/global-development-professionals-network...


From 8am to 4pm, 25-year-old Samina Khaskheli travels door-to-door in rural Pakistan handing out free samples of condoms, birth control pills, and intrauterine devices.

“I was told ‘This is sinful’,” Samina says about the initial opposition to her selling birth control. She took the job warily. Her off-the-map village, Allah Bachayo Khaskheli, is home to roughly 1,500 people in the country’s south-eastern Sindh province. The flatlands are covered by livestock, and economic desperation leaves women toiling alongside men as farmhands, livestock breeders and cotton pickers.

Samina is a worker for the Marginalised Area Reproductive Health Viable Initiative – Marvi – once a popular emblem of female independence in Sindhi folklore. Today, Marvi refers to a network of literate or semi-literate village women aged 18 to 40 who travel door-to-door selling contraceptives. “In our village, there was no information about family planning. Many women died during childbirth,” says Samina about what inspired her to join.

Trained by the Karachi-based Health and Nutrition Development Society (Hands), roughly 1,600 Marvis are dispersed throughout Pakistan’s remotest villages, where government healthcare facilities are scant or nonexistent. In the Sanghar district where Samina’s village is located, at least 400 Marvis fill a gap left by a lack of government funded lady health workers (LHWs).


Pakistan’s contraceptive prevalence rate is low – out of a population of more than 190 million, only 35% of women aged 15-49 use contraception. Nevertheless, demand is high in rural areas, where women give birth to an average of 4.2 children, compared to 3.2 children in cities. “In villages, electricity is not there and health facilities are not there, but the need for contraceptives certainly is,” says Dr Talat Abro, the deputy secretary of reproductive health service for Sindh’s population welfare department.

Marvi workers receive a six-day initial training by Hands and have their sessions in the field supervised by LHWs. Marvis emerge from the underserved populations they work with, so understand how family planning is best presented to the women they target.

“I wish I had learned about birth control 15 years ago,” says Azima Khaskheli, a 45-year-old livestock breeder in Allah Bachayo Khaskheli village, her black bangles clinking together as goats bleat nearby.

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“We are not trying to limit the number of children – a woman or a family has a right to choose as many number of children as they want, but they must keep in mind the pregnancy period is important for a woman’s health,” says Anjum Fatima, the general manager for health at Hands.

Opposition to birth control in Pakistan often takes on a religious hue, so Marvis are trained to sensitise local religious leaders on the health benefits of family planning. The Marvi programme relies on community mobilisers – ranging from religious leaders to influential landlords – to communicate the benefits of contraceptives. In 2014, approximately 40 Islamic religious leaders approved birth spacing for women in Pakistan. Samina adds that she enjoys the support of the village’s maulvis, or religious authorities, who endorse her door-to-door campaign, and never issue anti-contraceptive messaging over the mosque’s loudspeakers.


“Before the culture was rigid, but now they’ve gradually accepted family planning,” says Samina, the Marvi worker, motioning to the group huddled around her. “I am proud I can teach women about both the Qur’an and birth control.”

[Riaz Haq]

#Saudi #German Hospitals to foray into #Pakistan with 150-200 beds each Bahria Town in #Islamabad #Lahore #Karachi

http://gulfnews.com/news/uae/health/saudi-german-hospitals-to-foray...

The Saudi German Hospitals (SGH) group will build and manage hospitals in Bahria Town gated-communities in Pakistan, top management of the two companies announced on Thursday in Dubai.

The partnership will revolutionise Pakistan’s health care sector, eliminating the need for Pakistanis to travel to the West for treatment, Riaz Malik, chairman of Bahria Town, said at a press conference at Saudi German Hospital Dubai, where Sobhi Batterjee, president of Bait Al Batterjee (BAB) Medical Company, the founder of SGH, also spoke.

Under the agreement, SGH will build a 150-300 bed hospital in each Bahria Town development, starting with Lahore, Karachi and Islamabad in the first stage. BAB will also take over the upcoming new hospital of Bahria Town in Lahore as an operator and possibly also manage all hospitals of Bahria Town.

Each SGH-built hospital will have an investment of $100 million (Dh367 million), Batterjee said, and be built on a 12-acre plot of land provided for free in Bahria Town communities.

Malik said Bahria Town hospitals “will not stop treatment because of [patients’] financial problems. Bahria Town will put in its own money [to cover the remaining cost]”.

Batterjee said the partnership will lead to “reverse medical tourism” where patients and doctors from outside Pakistan will travel to SGH and SGH-managed hospitals in Pakistan. He said SGH’s foray in Pakistan will set a benchmark to which all other health care facilities will be compared.

“This will increase the corporate investment injection into health care, which is missing in Pakistan. Health care is an industry in itself, many people miss that fact,” Batterjee added.

Malik said Bahria Town hospitals meanwhile will gain from the 30-year expertise of SGH. “Unfortunately, there are too many health issues in Pakistan. We wanted to focus on this sector and after researching for the best health care provider, we found that SGH would be our ideal partner,” Malik added. “We are one team and I commit to giving Pakistan the best treatment ever,” said Batterjee.

[Riaz Haq]

How #Technology is Reaching #Pakistan’s Children with the #Polio Vaccine. #smartphones #apps #digital http://on.natgeo.com/2ah4OO0 via @NatGeo

Rotary conducts trainings for Lady Health Workers (LHWs) on cell phone reporting at its Rotary Resource Center in Nowshera, Khyber Pakhtunkhwa. “I was the only female at the time the program started, and I’ve been involved for the past eight years,” says health worker Malkabalees. Today, Rotary has trained more than 500 LHWs.

Specific codes are assigned to various maternal, newborn and child health indicators (pregnancies, deliveries, newborn deaths, maternal deaths, etc) and immunization indicators (immunizations administered, refusals, missed children, etc).

Community midwives and female health workers collect the data, and send it using specific codes to a server through SMS. Government and polio eradication leaders use the data to assess trends and gaps in the program.

Lady Health Worker Malkabalees teaches a fellow health worker to report a refusal, and enter the reason (e.g. religious, fear, lack of understanding). Rotary and its partners use this data to create strategies to combat refusals, such as involving religious leaders to educate their communities about the importance and safety of the vaccine.