THE Lady Health Workers Programme is the only pro-poor initiative in the country today directly delivering critical health services, but LHWs have been designated as a dying cadre in Punjab. Their services are to be ‘outsourced’ in the future, for the given reason that LHWs are blackmailing the government with protracted sit-ins for a better service structure and payment of pending salaries. Instead of addressing their grievances and strengthening the cadre’s role in primary healthcare, the province has decided to throw the baby out with the bathwater.
Much has been written about the success of the programme, introduced by Benazir Bhutto’s government in 1994 with technical support from WHO. In a country that spends an abysmally low portion of its GDP (0.91 per cent) on health, this particular community-based programme has improved health outcomes of large swathes of the population, especially in rural areas. The programme is recognised globally for its positive outcomes, and was duly supported by subsequent governments (except the last).
In the face of a chronic shortage of human resources in the health sector, the programme provides essential services to the poor, in line with the Alma Ata Declaration and later the MDGs. LHWs are agents of rural change, and the first point of contact between the community and the formal healthcare system. They are trained to create awareness about health, hygiene, sanitation and management of TB and hepatitis, handle minor illnesses, and play a vital role in polio eradication, vaccination, disease prevention, nutrition, contraception and, most importantly, childbirth, thus reducing maternal and child mortality rates.
Why does Punjab want to undo a successful programme?
Since 1994, the government has deployed 106,000 LHWs in the field, with one LHW looking after 1,500 people or 200 households on a salary as low as Rs14,000 per month. Candidates with a minimum of eight years of education are trained to cover 20 critical health-related tasks and provided a basic kit of medical supplies. Lady Health Supervisors monitor the LHWs’ performance and send monthly reports to district health officers.
An evaluation of the programme by Oxford Policy Management in 2008 found that the population served by LHWs had better health indicators than the national population despite being underfunded, with suboptimal facilities and political interference. A study in 2012 also noted a 20pc reduction in neonatal mortality rates in Hala district within a short period of LHWs receiving training by AKU faculty.
LHWs have heavy workloads and poor salaries; they live in precarious environments, encounter gender discrimination, patriarchal prejudice, sexual harassment, blackmail, threats and even assassination — 96 LHWs have been killed so far — when they are used in polio and other vaccination campaigns. Then there are ‘ghost’ LHWs, whose salaries are siphoned off by corrupt health department officials. Monthly supplies of medicines are pilfered instead of reaching LHWs. Even the vehicles given to Lady Health Supervisors are misused by higher officials. They are denigrated by government functionaries and not accorded respect as professional health workers.
In India, Auxiliary Nurse Midwives are primary healthcare female workers serving mainly rural communities in conjunction with Accredited Social Health Activists. As reported by The Hindu in September 2017, the mortality rate of children under five declined in 2015, partly due to interventions by ANMs and ASHAs. The incidence of child mortality in Sri Lanka and Bangladesh is eight and 33 per 1,000 live births respectively, while in Pakistan, it was 81 per 1,000 live births in 2015 — the highest in South Asia according to Unicef.
That the continual clipping of LHWs’ funding over the years has a direct bearing on these shameful statistics is lost on Punjab’s bureaucracy. Their intransigence towards the LHWs, including non-regularisation of their services, instituting cases against them for protesting for their rights, and non-payment of salaries has further debilitated the cadre in a skewed misogynistic culture that in any case was resisting their activities in villages. It is now up to the new provincial health minister to set things right.
Although the LHW Programme needs further improvement with more training, supervision and better outreach, it is being supported by all the provinces except Punjab, and it is included in their primary health service reforms. In fact, the Sindh government with the John Hopkins Centre has introduced an Android-based mobile tool kit for LHWs, and also announced additional hiring of 3,200 LHWs, out of which 1,060 will be deployed in Tharparkar. However, it needs to do more to expand their present coverage of only 65pc of the Sindh population, and increase their salaries as such a vital programme cannot be sustained on a shoestring budget.
The writer is a former federal secretary.
Published in Dawn, September 16th, 2018