Shahnaz Gul, a Lady Health Worker, visits six-day-old Naveed and his mother in Muzzafargarh District, Pakistan. Photo credit: Ayesha Vellani/Save the Children

As a Lady Health Worker, Shahnaz Gul, 29, is responsible for the health of 259 families. She says “My duties include looking after pregnant mothers and making sure they are vaccinated, and informing them about check-ups. I also keep a record of their children, monitor their health and make sure they are vaccinated on time.

It’s common in rural Punjab for pregnant mothers to deliver their newborn babies at home. Families seek the services of traditional birth attendants who are neither skilled nor trained in prenatal and maternal health, to help with the deliveries. A lot of problems ensue for mothers and babies born this way. Often mothers develop infections, and babies get sick and even die as a result of inadequate care.

Lady Health Workers are at the forefront of the revolution that is better nutrition. Our work focuses primarily on educating mothers about how to look after their children. We emphasise exclusive breastfeeding for babies and tell mothers and their families the importance of breastmilk and how it can protect them from a host of diseases and infections. We try to instil better nutrition practices to ensure that families stay healthy. We tell mothers not to use
pacifiers, since they cause a lot of infections. Hygiene is a core component of our work and we stress its importance everywhere.

Sometimes we do face resistance. One of the greatest obstacles we face is from Basic Health Unit (BHU) staff. We refer pregnant women to BHUs for checkups and even delivery. The BHU staff often demand a fee, which many of these women can’t afford. The women return to us, complaining and hopeless. Then we have to intervene and convince the BHU staff not to charge them or to take a subsidised fee. That’s our biggest problem.

Our work as Lady Health Workers has reduced maternal and child mortality and health related problems. Our struggles are paying off. The community looks up to me and consults me about health problems. It pleases me tremendously to see the difference I’ve made. I hope to continue to do my best for society.”

Neonatal mortality rate  (per 1,000 live births) (2011) 36
Under-five mortality rate (per 1,000 live births) (2011) 72
Maternal mortality ratio (per 100,000 live births) (2010) 260
Number of doctors, nurses and midwives per 10,000 people (2010) 13.6
Births attended by skilled personnel (2011) 45%
Total expenditure on health as a percentage of gross domestic product (2011) 2.5%
General government expenditure on health as a percentage of total expenditure on health (2011) 27%

Health services in Pakistan were devolved in 2011 following a constitutional amendment. The federal government has responsibility for health information, interprovincial coordination and health regulation. All other health responsibilities have been devolved to the provinces. This provides an opportunity to reform the health sector in Pakistan though provinces are being held back by the slow release of funds and lack of coherent policies.

Levels of government expenditure on public healthcare are low in Pakistan. As a result, the population faces high rates of out-of-pocket expenditure and the private sector provides three-quarters of health services.

Three categories of public sector community health workers – Lady Health Workers, Community Midwives and Vaccinators have played an important role in scaling up access to primary health care services, particularly in rural and remote communities. Recent legislation commits to regularise the role of these cadres and increase their remuneration but implementation of these policies has been delayed by the devolution process. Many vacant posts remain unfilled and in parts of the country, frontline health workers are being prevented from providing essential services due to being the target of attacks.

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