LHW Balochistan Report

Lady Health Worker Programme
External Evaluation of the

National Programme for
Family Planning and
Primary Health Care
Balochistan
Survey Report
Oxford Policy Management

August 2009
Reports from this evaluation
1. Summary of Results
2. Management Review
3. Systems Review
4. Financial and Economic Analysis
5. Quantitative Survey Report
6. Punjab Survey Report
7. Sindh Survey Report
8. NWFP Survey Report
9. Balochistan Survey Report
10. AJK/FANA Survey Report
11. Lady Health Worker Study on Socio-Economic Benefits and Experiences
Cover photo: Village girl in rural Punjab

Acknowledgements
This evaluation of the National Programme for Family Planning and Primary Health Care was
undertaken by Oxford Policy Management UK and Save the Children Fund, and funded by
the Canadian International Development Agency, through a World Bank Trust Fund.
The core evaluation team included: Simon Hunt (Team Leader); Shafique Arif (Survey
Manager); Dr Imtiaz Malang, Dr Tehzeeb Zulfiqar, Philippa Wood (Management and
Systems Review); Rana Asad Amin, Mark Essex, Georgina Rawle (Financial Experts); Sarah
Javaid, Emily Wylde (Qualitative Research); Patrick Ward (Technical Team Leader); Alex
Hurrell and Luca Pellerano (Survey Design and Analysis); Juan Munoz (Sample Design);
Dr Laila Salim (Quantitative Survey Design); Iftikhar Cheema, Alamgir Morthali (Data Entry
and Data Analysis). The design and analysis of the Quantitative Surveys was managed by
Alex Hurrell and Patrick Ward. Other members of the OPM evaluation team assisted in the
design of the survey and questionnaires, particularly Simon Hunt and Juan Munoz, Luca
Pellerano, Shafique Arif, Laila Salim, Tehzeeb Zulfiqar and Philippa Wood. A team of
analysts worked on the analysis and report writing. They were: Shafique Arif, Luca Pellerano,
Alex Hurrell, Ramlatu Attah, Sophie Witter, Tehzeeb Zulfiqar, Phillipa Wood and Iftikhar
Cheema. Dr Salim Sadruddin and Dr Aman ullah Khan (Save the Children Fund) assisted
the Quantitative team and contributed to the peer review of the reports. Mr Ejaz Rahim was
involved in an advisory capacity and peer review. The team is also grateful for the external
peer review provided by Dr Franklin White.
A large team of supervisors, enumerators and others worked on the survey fieldwork. They
were: Muhammad Shafique Arif (Survey Manager); Abdul Rashid Bhatti (Survey Coordinator);
Amir Khan (Survey Coordinator); Rubina Akbar (Survey Coordinator); Sabeena Gul (Survey
Coordinator); Sadia Sharif (Office Coordinator); Kamran Bhutta (Provincial Coordinator); Tufail
Laghari (Provincial Coordinator); Adeela Ahmad (Editor); Ayesha Ashfaq (Editor); Kashif Amin
(Editor); Lubna Rauf (Editor); Madeeha Ali (Editor); Sabiha Masud (Editor); Anila Yasmin
(Supervisor); Aysha Noreen (Supervisor); Azra Jabeen (Supervisor); Benazir Bibi (Supervisor);
Fakhra Ahmed (Supervisor); Hamida Narejo (Supervisor); Humera Soomro (Supervisor);
Rabia Basri (Supervisor); Raj Bibi (Supervisor); Saira Memon (Supervisor); Shazia Batool
(Supervisor); Shazia Qudrat (Supervisor); Zubaida Baloch (Supervisor); Abdul Wadood
(Logistics i/c); Aftab Mangi (Logistics i/c); Ahmed Hassan (Logistics i/c); Azam Hussain
(Logistics i/c); Barkat Shah Kakar (Logistics i/c); Imdad Ullah (Logistics i/c); Khizar Hussain
(Logistics i/c); Mohammad Qasim Hasni (Logistics i/c); Mohsin-ud-din Muhammad (Logistics
i/c); Rashid Unar (Logistics i/c); Wahid Marri (Logistics i/c); Waseem Nawaz (Logistics i/c);
Zahoor Ahmad (Logistics i/c); Abida Bibi (Interviewer); Anila Gohar (Interviewer); Asia Abro
(Interviewer); Asma Ahmad (Interviewer); Farah Deeba (Interviewer); Gul-e-Rana (Interviewer);
Haleema Baloch (Interviewer); Iram Jilani (Interviewer); Iram Latif (Interviewer); Jamal Khatoon
(Interviewer); Nafees Manzoor (Interviewer); Naheed Mustafa (Interviewer); Nasreen Gul
(Interviewer); Naureen Anjum (Interviewer); Nelofar Hassan (Interviewer); Noushin
(Interviewer); Rabia Bashir (Interviewer); Rabia Rashid (Interviewer); Rashida Baloch
(Interviewer) Rukhsana Jamali (Interviewer); Salma Aziz (Interviewer); Samina Abbas
(Interviewer); Samina Bibi (Interviewer); Shabana Hingoro (Interviewer); Shazia Malik
(Interviewer); Shumaila (Interviewer). The evaluation team thank all of them for the hard work
put into the survey.
The cooperation and assistance provided by staff members of the National Programme for
Family Planning and Primary Health Care throughout the country, including the Lady Health
Workers and their supervisors, is also gratefully acknowledged, as is the cooperation of the
householders, community members and health facility staff interviewed.
i
LHWP – Balochistan Survey Report
OPM evaluation team also want to thank the peer reviewers designated by the National
Programme for Family Planning and Primary Health Care who reviewed all the reports: The
Peer reviewers included:
• Dr Franklin White (Pacific Health and Development Sciences)

• Dr Shakila Zaman (Health Services Academy)
• Dr Raza Mohammad Zaidi (DFID, Pakistan)
• Dr Fazal Hakeem Khattak (Planning Commission)
• Dr Inam Ul Haq (World Bank)
• Ms. Sadia Ahmad (CIDA).
ii
Executive summary
The Lady Health Worker Programme (LHWP) is an increasingly important element in the
Government of Pakistan’s plan to improve the health status of women and children in
villages and poor urban areas. The Programme has expanded substantially since it was
founded in the early 1990s. Over 80 million people now have access to services from a Lady
Health Worker (LHW) in their community.
The third independent programme evaluation (the 3rd Evaluation) in 2000 showed that these
services have a positive impact on the health of the poor, particularly women and children. It
showed that through their work, LHWs are contributing directly to improved hygiene and
higher levels of contraceptive use, iron supplementation and vaccination amongst their
clients. In 2008, over 90 percent of communities reported that the LHW has generally
improved peoples lives and that there have been improvements in health due to LHWs work.
This report comprises part of the 4th Evaluation. Specifically, it reports key findings of the
quantitative survey on the performance of the LHWP in Balochistan. Where appropriate,
these findings are compared nationally and with the results of the 3rd Evaluation (2000).
Service delivery
In terms of LHWP service delivery, LHWs in Balochistan are working harder than they were
in 2000. Nationally, they report an average of 30 hours per week of work, compared with 20
in 2000, although an appreciable part of this increase is accounted for by increased activity
on National Immunisation Days (NIDs).
In Balochistan, LHWs are providing many services to a higher proportion of their clients than
they were in 2000. The proportion of eligible clients receiving services provided by LHWs
varies according to the type of service. The LHW performance score, which measures the
coverage rate of preventive and promotive services, increased from 42 percent to 52 percent
nationally, and by a greater amount in Balochistan from 31 percent to 54 percent. Over a half
of the LHWs’ clients in Balochistan are now receiving the preventive and promotive services
for which they are eligible.
In delivering these services the LHW should be visiting all of her registered households at
least once every two months. In Balochistan this would mean visiting an average of 10
households per week, as she has on average, 86 registered households. If she was following
the Programme’s norm of visiting five households per day, for six days a week, she would
cover all of her registered households in three weeks. On an average Lady Health Worker in
Balochistan is actually visiting 15 households per week – the lowest level across the country.
Moreover, 19 percent of households in Balochistan had not received a visit in the past three
months.
In addition to providing preventive and promotive services, curative services continue to be

an important part of the workload, although the use of LHW curative services by adults
appears to have declined slightly since the previous evaluation, and fewer LHWs report
having seen an emergency case than in the previous evaluation. The survey found an
average of 86 households registered per LHW in Balochistan, compared with the national
average of 131.
The results from the survey showed that overall 37 percent of LHWs in Balochistan have
worked on National Immunisation Days (NIDs) for the EPI Programme, in the past three
iii
months, for an average of nine days, of which 68 percent of these worked outside of their
catchment area. Some 95 percent of those LHWs working on NIDs in Balochistan received
extra payment.
Differing levels of performance

As in the previous evaluation, a composite performance score was calculated for every
interviewed LHW. The average score for Balochistan is just above the national performance
score. The score can also be used to classify Lady Health Workers into: High Performers,
Good Performers, Below Average and Poor Performers. High Performing LHWs provide
nearly four out of five of their eligible clients with relevant services. Poor Performers on the
other hand, are providing a service to just over a quarter of their eligible clients.
In Balochistan 17 percent of LHWs are High Performers and 24 percent are Poor Performers
compared to 25 percent in each category nationwide.
Statistical analysis was used to identify the factors associated with variations in LHW
performance nationally. The analysis identified a range of factors which help to explain these
variations, some of which are within the control of the LHWP and which therefore imply some
clear policy implications. Specifically, efforts should be made to:
• Retain experienced LHWs;

• Ensure LHWs are working the full hours required of them – this requires adequate
supervision support – but LHWs should not be working a seven day week;
• Ensure that LHW supervisors are themselves regularly and effectively supervised by
the FPO and that performance monitoring tools such as the diaries and work plans
continue to be used;
• Encourage women’s health committees to be established/maintained in all served
areas;
• Maintain a focus on MIS reporting – in particular, making clear the services that the
LHW should be providing, and ensuring LHWs understand that their performance in
delivering these services is being monitored;
• Encourage DPIU’s to instigate effective LHW performance management regimes with
effective procedures for reporting and sanctioning LHW non-performance. Punishing
LHWs with salary deductions or delays does not appear to be an effective response
to non-performance, in contrast to providing additional training, ideally directed at the
specific area of non-performance; and
• Ensure all served health facilities have an individual with overall responsibility for
overseeing LHWP activities.
The knowledge test

The survey asked LHWs and their supervisors a series of questions designed to assess their
clinical knowledge levels. This was found to be high in many areas though on average LHWs
in Balochistan scored 64 percent. These scores are the lowest relative to the rest of the
country where the national average for LHWs was 74 percent. LHWs’ average knowledge
score has increased since 2000 in Balochistan, though slightly less than the overall
improvement nationally.
The improvements have not been uniform, with knowledge improving in some topic areas but
not in others. A minority of LHWs continue to lack basic clinical knowledge. The low scores
iv
and lack of in-depth knowledge of this minority of LHWs could have serious clinical
consequences as well as undermining the professional reputation of the programme.
The Programme needs to continue to develop its on-going system of knowledge assessment
and reinforcement for all LHWs and LHSs. It has been shown that education, effective
training and supervision and good district management practices are important factors in
determining LHW levels of knowledge. These results also have clear policy implications for
the programme. Specifically, efforts should be made to:

• Strive to ensure new LHW recruits have high levels of education. Since this is often at
odds with efforts to increase coverage (remaining unserved areas tend to have fewer
education women), this may require innovative approaches;
• Maintain and improve the frequency and quality of refresher training courses. Current
training courses should be reviewed to ensure they focus on areas where LHW
knowledge is weakest (e.g. growth monitoring, diarrhoea treatment, pneumonia);
• Make efforts to monitor and maintain the LHWs’ supervisors' knowledge levels; and
overseeing LHWP activities, and that within each district regular meetings are held
between these individuals and the DPIU.
Organisational support – supervision, pay and supplies

Nearly all LHWs now have supervisors. However, less than half of LHWs in Balochistan had
received at least one visit from their supervisor in the past month (compared to 80 percent
nationally), though many more LHWs in Balochistan had attended a monthly meeting at the
health facility in the past month (65 percent). Nearly two thirds of LHWs in the Balochistan
reported that the LHS had used her checklist in her previous supervision visit (compared to
78 percent nationally).
LHWs and supervisors should expect to receive their pay monthly in full and on time. Only
Balochistan 72 percent of LHWs had received their pay within the past three months. This is
a substantial increase in the level of such late payments compared with 2000, against
improvements nationwide, and so is a cause for concern.
Medical supplies and equipment are essential in ensuring an effective community health
service and ensuring the credibility of the LHW. The previous evaluation found a substantial
problem with stock outs, with many LHWs out of stock of medicines for a significant period.
The 4th Evaluation has shown there remains a significant problem, with many LHWs having
key medicines out of stock for two months or more. Balochistan is the best performing
province in terms of keeping LHWs stocked up.
Looking ahead
The Programme has expanded substantially since 2000, at the same time as facing the
challenges due to decentralisation. As it has expanded, it has penetrated into more rural and
less advantaged areas, although it is still not reaching some of the most disadvantaged
areas.
At the same time, the Programme has managed to institute a number of improvements that
were identified as important in the previous evaluation. It has improved supervision and has
v
increased average levels of knowledge. The level of service delivery has increased. These
changes must all be recognised as significant achievements.
However, there remain a group of underperforming LHWs, whose working practices must be
further improved, and important gaps in LHWs’ knowledge. There remain also significant
failures in supply systems, both in medicines and equipment. These issues must be further
addressed going forwards.
vi
Table of contents
Acknowledgements ................................................................................................................... i
Executive summary ..................................................................................................................iii
List of tables and figures ......................................................................................................... ix
Abbreviations .......................................................................................................................... xi
1 Evaluating the Lady Health Worker Programme .......................................................... 1
1.1 Background ............................................................................................................ 1
1.2 Lady Health Worker Programme evaluation ........................................................... 1
1.3 Characteristics of Lady Health Workers ................................................................. 2
1.4 Key points ............................................................................................................... 5
2 Providing services at the doorstep ............................................................................... 7
2.1 Levels of service delivery ....................................................................................... 7
2.2 Delivery of curative services ................................................................................... 8
2.3 Activities in the community ..................................................................................... 9
2.4 Referral to health facilities .................................................................................... 10
2.5 Contribution to National Immunisation Days (NIDS)............................................. 11
2.6 Key points ............................................................................................................. 13
3 Levels of performance ................................................................................................ 15
3.1 Performance of Lady Health Workers in service delivery ..................................... 15
3.2 Explaining high performance ................................................................................ 16
3.3 Key points ............................................................................................................. 17
4 The Lady Health Worker workload ............................................................................. 19
4.1 Client registration .................................................................................................. 19
4.2 Time spent working .............................................................................................. 20
4.3 Household visits made and clients seen............................................................... 22
4.4 Taking on additional paid work ............................................................................. 24
4.5 Key points ............................................................................................................. 24
5 Knowledge, skills and training of Lady Health Workers and their supervisors ........... 25
5.1 The knowledge test .............................................................................................. 25
5.2 Improving knowledge through training .................................................................. 27
5.3 Explaining LHW knowledge levels ........................................................................ 28
5.4 Key points ............................................................................................................. 30
6 Supervision of Lady Health Workers .......................................................................... 31
6.1 Managing performance through supervision ........................................................ 31
6.2 Supervision of Lady Health Workers .................................................................... 31
6.3 Transportation ...................................................................................................... 33
6.4 Key points ............................................................................................................. 34
7 Programme salary payment and medical supply systems ......................................... 35
7.1 Performance of the pay system ............................................................................ 35
7.2 Supply of medicines and equipment ..................................................................... 35
vii
7.3 Improving distribution and supply ......................................................................... 36

7.4 Key points ............................................................................................................. 37
Annexes
Annex A The quantitative survey................................................................................... 41
Annex B Demographic and educational characteristics of LHWs ................................. 43
Annex C Service delivery of Lady Health Workers, by province ................................... 45
Annex D Creating a measure of performance for Lady Health Workers ....................... 49
Annex E Levels of performance .................................................................................... 51
Annex F Lady Health Worker activities and population coverage ................................. 53
Annex G The knowledge test......................................................................................... 57
Annex H The knowledge test results ............................................................................. 61
Annex I Training of Lady Health Workers and Lady Health supervisors ...................... 65
Annex J Supervision ..................................................................................................... 67
Annex K Work planning and reporting........................................................................... 69
Annex L Supplies of medicines and equipment ............................................................ 71
viii
List of tables and figures
Table 2.1 Consulting the Lady Health Worker for illness or injury, by province ................ 9
Table 2.2 Comparison on LHW reports on referrals to health facilities .......................... 11
Table 5.1 Percentage of LHW training that was provided by at least one female trainer27
Table 5.2 Type of refresher training received by LHW in the previous year, by province28
Table 7.1 Proportion of Lady Heath Workers receiving less salary than expected ........ 35
Table 7.2 Percentage of LHWs with stock outs for more than two months .................... 36
Table A.1 Sample breakdown by unit of observation ...................................................... 41
Table B.1 Demographic and educational characteristics of Lady Health Workers ......... 43
Table C.1 Lady Health Workers preventive and promotive services by province ........... 46
Table C.2 Lady Health Workers participation in National Immunisation Days (NIDS) .... 47
Table E.1 Different levels of performance amongst Lady Health Workers ..................... 51
Table F.1 Number of households and persons registered by Lady Health Workers ...... 53
Table F.2 Number of hours Lady Health Workers worked last week by type of activity . 54
Table F.3 Days worked by Lady Health Workers during last week ................................. 54
Table F.4 Number of household visits made by the LHW and number of clients seen
during the past week as reported by the client ............................................... 56
Table G.1 Scoring for general knowledge section of the knowledge test ........................ 57
Table G.2 Scoring for case-based section of the knowledge test ................................... 58
Table H.1 The knowledge test-general knowledge section, percentage of correct
answers given by LHWs, nationally and in Balochistan .................................. 61
Table H.2 The knowledge test-case based questions, percentage of correct answers
given by LHWs, nationally and in Balochistan ................................................ 62
Table I.1 Training Received by Lady Health Workers ................................................... 66
Table J.1 Supervision of Lady Health Workers .............................................................. 67
Table K.1 Lady Health Worker work planning and reporting ........................................... 69
Table L.1 Lady Health Worker stock of medicines, nationwide ...................................... 71
Table L.2 Percentage of Lady Health Workers with functional equipment and
administrative materials .................................................................................. 71
Figure 1.1 Percentage of LHWs who have replaced an LHW in their catchment area ...... 3
Figure 1.2 Percentage of LHWs serving their original catchment area .............................. 4
Figure 1.3 Percentage of LHWs with the use of a mobile phone, by province .................. 4
Figure 2.1 Lady Health Workers average coverage of preventive and promotive services
to eligible individuals (performance score) ....................................................... 8
Figure 2.2 Activity and meetings of women’s health committees, by province ................ 10
Figure 2.3 Place of referral of last acute case by LHW in Balochistan ............................ 11
Figure 2.4 Participation of LHWs in NIDS in the past three months ................................ 12
Figure 3.1 Comparing Lady Health Worker provision of service by performance category
between 2000 and 2008 ................................................................................. 15
Figure 3.2 Proportion of Balochistan Lady Health Workers in each performance category16
Figure 4.1 Average number of persons registered with the LHWs .................................. 19
ix
Figure 4.2 Comparison of the number of hours worked last week by LHWs ................... 20
Figure 4.3 Number of days worked by the LHW in the previous week, by province ........ 21
Figure 4.4 Allocation of work time by Lady Health Workers in Balochistan ..................... 22
Figure 4.5 Average number of household visits made last week by Lady Health Worker23
Figure 4.6 Average number of clients seen last week by Lady Health Worker ................ 23
Figure 4.7 Proportion of Lady Health Workers with another paid job .............................. 24
Figure 5.1 Knowledge score for Lady Health Workers (2000 and 2008) ......................... 26
Figure 5.2 Percentage LHWs who have received on the job training in the past year and
training at their last monthly meeting, by province .......................................... 28
Figure 6.1 Percentage of Lady Health Workers visited by supervisor in the past month for
supervision...................................................................................................... 32
Figure 6.2 Percentage of LHWs who reported the LHS using her checklist in her previous
supervision visit .............................................................................................. 32
Figure 6.3 Percentage of Lady Health Workers who have attended the monthly meeting
at their health facility in the past month .......................................................... 33
Figure 7.1 Percentage of LHWs paid within the past three months ................................. 35
x
Abbreviations
ADC Assistant District Coordinator

AIDS Acquired Immune Deficiency Syndrome
AJK Azad Jammu and Kashmir
APC Assistant Provincial Coordinator
BHU Basic Health Unit
DC District Coordinator
DPIU District Programme Implementation Unit
EDO-H Executive District Officer of Health
EPI Expanded Programme of Immunisation
FANA Federally Administered Northern Areas
FATA Federally Administered Tribal Areas
FLCF First Level Care Facility
FPIU Federal Programme Implementation Unit
FPO Field Programme Officer
FY Financial Year
GOP Government of Pakistan
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
LHS Lady Health Supervisor
LHW Lady Health Worker
LHWP Lady Health Worker Programme
MCH Maternal and Child Health
MIS Management Information System
MoH Ministry of Health
NAs Northern Areas (FANA)
NIDs National Immunisation Days
NWFP North Western Frontier Province
PC Provincial Coordinator
PC-1 Planning Commission 1
PHC Primary Health Care
POL Petrol, Oil and Lubrication
PPIU Provincial Programme Implementation Unit
PSU Primary Sampling Unit
RHC Rural Health Centre
xi
Evaluating the Lady Health Worker Programme
1 Evaluating the Lady Health Worker Programme
1.1 Background
The Lady Health Worker Programme (LHWP) is an important element in the Government of
Pakistan’s plan to raise the health status of women and children in rural villages and poor
urban areas. The Programme was launched in April 1994 as a Federal development
programme funded by the Ministry of Health (MoH), and implemented by both the MoH and
the provincial Departments of Health. The Lady Health Worker Programme (LHWP) has, with
increased funding, delivered more services in the past five years. Since the previous
evaluation in 2000, the Programme has expanded from 38,000 LHWs to 90,000 Lady Health
Workers (LHWs), only 10,000 short of the target of 100,000. The LHWs are now an
occupational group that is recognized by the community for the services that they are able to
deliver. The organizational structure and service delivery model has remained the same.
The main goal of the programme was to establish a primary health care service:
• Providing accessible promotive, preventive, curative and rehabilitative services to the

entire population;
• Bringing about community participation;
• Improving the utilisation of health facilities;
• Expanding availability of family planning services in urban slums and rural areas of
Pakistan; and
• Gradually integrating existing health care delivery programmes like EPI, Malaria
control, Nutrition, MCH within the programme.
1.2 Lady Health Worker Programme evaluation

This report1 presents information on the performance of the LHWP in Balochistan against the
background of information on the national picture. It is based on data collected through
quantitative surveys undertaken in 2008 as part of the fourth independent evaluation of the
LHWP (the 4th Evaluation). Wherever appropriate the report compares findings with those of
the previous evaluation (the 3rd Evaluation), conducted in 2000.
Specifically, this report covers the following areas:
• Characteristics of LHWs;
• The range and level of preventive, promotive, curative and referral services provided
by the LHW;
• Differences between high performing and poor performing LHWs;
• Activities of the LHW including hours of work and the number of registered clients;
• Knowledge and skills levels that the LHWs bring to their jobs; and
• Quality of the organisational support received by the LHW.
1
This report is one of a series of ten reports providing the results of the evaluation. Provincial reports have been
written for Punjab and ICT, NWFP, AJK/FANA, Sindh and Balochistan. FATA was not able to be included in the
survey due to security concerns for the field workers. In addition there are five national level reports: the Final
Report which summaries the key findings, the Quantitative Survey Report providing an extensive analysis of the
quantitative results, the Financial and Economic Analysis presenting costs and spending patterns of the LHWP,
the Management and Systems Review, and the Study of the Lady Health Worker, Socio-Economic Benefits and
Experience.
1
This information should support programme managers in Balochistan and at the Federal
level to identify initiatives to improve the quality and level of service delivery.
Note that two districts in NWFP and all seven districts in FATA were excluded from the
sample frame in 2008 due to high levels of insecurity. This has implications for the
comparability of the NWFP results with the previous evaluation. Furthermore, in addition to
the nine districts in FATA and NWFP that were excluded from the sample frame, some of the
selected districts were subsequently found to be insecure and therefore had to be dropped
from the survey. In NWFP, three of the 12 sampled districts (Lakki, Karak and Dir Lower) and
two served and two unserved FLCF clusters in the Malakand district could not be surveyed
due to insecurity. These insecure areas were not replaced because this could have
introduced bias.2
The implication of this is that the survey is representative of all areas in Pakistan that were
secure at the time of the fieldwork. In contrast, the 3rd Evaluation was representative of all
Pakistan, because the whole country was accessible to field teams in 2000. This needs to
taken into account when comparing results from the two surveys. Particular care needs to be
taken when comparing NWFP/FATA estimates from 2000 with the NWFP 2008 estimates,
which exclude FATA completely and are only representative of those parts of NWFP that
were secure enough to be accessible at the time of the survey.
In addition to problems of sample comparability caused by insecurity, there was an additional

problem caused by the fact that the district sample frame was incomplete. The district
sample frame, derived from the served FLCF and LHW lists provided by the LHWP-MIS unit,
only contained 118 districts, whereas there were actually 133 districts in Pakistan in April
2008 when the sample frame was constructed. Thus, 15 districts were missing from the
sample frame. The problem is most acute for Balochistan, since 11 of the 15 ‘missed’
districts are in Balochistan. However, analysis has been undertaken (see Annex A of the
Main Quantitative Report for details) that shows that, whilst some care should be taken in
interpreting provincial-level trends for Balochistan, the overall national results and the
provincial estimates for the other provinces are unaffected.
1.3 Characteristics of Lady Health Workers

The Programme has specific recruitment criteria for Lady Health Workers. It is important for
Programme credibility and reputation as a professional service that these criteria, once
determined, are adhered to.3
LHWs should be between twenty and fifty years old, when recruited, though if married,
eighteen and nineteen-year-olds are acceptable. Only 1 percent of LHWs were under twenty
years old at the time of the survey.
In Balochistan, LHWs tend to be younger than the national average with 33 percent under
age 25, compared to 14 percent nationally. The Programme prefers LHWs to be married and
58 percent of the LHWs in Balochistan meet this criterion. This is lower than the national
average of 66 percent (Annex Table B.1). The assumption is that married LHWs are more
likely to have gathered knowledge and skills from personal experience, particularly with
regard to family planning practices and child and maternal health.
2
See Quantitative Survey Report for more information.
3
See Quantitative Survey Report for more information.
2
LHWs should be educated to at least the eighth class, though it is preferable for them to be
matriculated. All Lady Health Workers in Balochistan report having an education of at least
an eight class pass and 70 percent have class ten or above. Sixty two per cent of LHWs in
Balochistan could confirm class achievement through showing their school certificate.
The vast majority of LHWs live in the village/mohalla in which they work, as required by
Programme standards. In Balochistan 2 percent are non-resident, in line with the national
average. LHWs are very much part of the community they work in. In Balochistan 83 percent
of the LHWs were born within the community and a further 16 percent have been resident for
more than five years (Annex Table B.1). The Programme in Balochistan has been successful
in ensuring that the vast majority of LHWs and their supervisors meet the educational, age
and residency criteria.
Due to staff turnover, villages are starting to have a second generation of Lady Health
Workers. In Balochistan, 15 percent of LHWs are currently working in a catchment area that
was already being served by the Programme before they took over (Figure 1.1). This
compares to 29 percent nationally.
LHWs tend not to move from their village, particularly in Balochistan (Figure 1.2). Some 96
percent of serving LHWs in Balochistan are still serving their original catchment area.
Figure 1.1 Percentage of LHWs who have replaced an LHW in their

catchment area
50
Percentage of LHWs
40
30
20
10
0
Punjab/IC Balochist
Sindh NWFP AJK/FANA
T an
Percentage replaced 30 26 30 15 37
an LHW
Source: Quantitative Survey Report 2008.
3
Figure 1.2 Percentage of LHWs serving their original catchment area
100
Percentage of LHWs
90
80
70
60
50
Punjab/I Balochist
Sindh NWFP AJK/FANA
CT an
Percentage serving the 86 86 91 96 86
same catchment area
LHWs and Mobile Phones
Access to a mobile phone could potentially enable the LHW to strengthen the link between
the community and health care providers, for example by facilitating communication between
the LHW and health facilities in regard to referral cases. In Balochistan, only 36 percent of
LHWs have use of a mobile phone, compared to 79 percent nationally (Figure 1.3). Many of
these have shared access with their husband or another family member.
Figure 1.3 Percentage of LHWs with the use of a mobile phone, by province
100
80
Percentage of LHWs
60
40
20
0
Balochista
Punjab Sindh NWFP AJK/FANA
n
Access to mobile 85 62 82 36 74
phone
4
1.4 Key points

• In Balochistan as in the other provinces, the Programme has been successful in
ensuring that the vast majority of LHWs meet the educational, age and residency
criteria.
• Due to staff turnover, villages are starting to have a second generation of Lady Health
Workers. Serving LHWs do not often change their catchment area, however – in
Balochistan 96 percent of serving LHWs are still serving their original catchment area.
• Just over a third of the LHWs have access to a mobile phone, the lowest among all
provinces.
5
Providing services at the doorstep
2 Providing services at the doorstep
2.1 Levels of service delivery

The range of services that LHWs provide to their clients includes:
• Hygiene education on drinking water and sanitation;

• Nutritional advice and growth monitoring;
• Monitoring and advising women on their health, and that of their babies;
• Motivating and educating women on family planning; and
• Promoting and facilitating vaccination.
The survey shows that over 80 million people in Pakistan are receiving services from the
LHW and that these services are making a difference. LHWs are providing health services to
the poor, particularly women and children, which contribute directly to higher levels of
contraceptive use, antenatal care, iron supplementation, neo-natal check-ups, and
immunisation amongst their clients.4
Overall there has been some increase in the level service provision in all provinces,5
although variations exist between them. The overall rate of LHW service provision, as
assessed by the percentage of eligible individuals receiving services from LHW, has
increased in Balochistan, from 31 to 54 percent (when considering all LHWs). However,
comparing provinces there is variation, with Sindh and Punjab/ICT having the lowest
performing LHWs on average on this measure. This contrasts with 2000, when Balochistan
was singled out as worst performing province (Figure 2.1).6 However, as well as the rate of
LHW service delivery, which is what is being measured here, the total number of households
registered and clients served is also important. Figure 4.1 and Figure 4.5 in Section 4 below
show that in both these two measures Punjab/ICT LHWs are the most active and
Balochistan LHWs the least.
4
See the Quantitative Survey Report for information on the impact of the LHW on health outcomes.
5
‘Province’ is used throughout the Report to refer to both Provinces and Federally Administrated Areas.
6
See Annex C: Service delivery of Lady Health Workers, by province.
7
Figure 2.1 Lady Health Workers average coverage of preventive and

promotive services to eligible individuals (performance score)
Percentage of eligible individuals receivin
100
services from LHW 80
60
40
20
0
Balochista
Punjab Sindh NWFP AJK/FANA
n
2000/01 42 40 47 31 52
2008 53 50 54 54 58
Source: Quantitative Survey Report 2000 and 2008
Similarly, provincial variations exist in the type of service provided. For example, 73 percent
of households registered with the LHW in Balochistan reported that the LHW has talked to
them at some point about ways to improve the cleanliness of drinking water. . The survey
also revealed that 68 percent of currently married women aged 15-49 in Balochistan, who
are current users of modern contraceptives, were supplied by the LHW.
The analysis of what factors can help increase LHW performance is presented in Chapter 3.
2.2 Delivery of curative services

While the majority of individuals in the served population who are sick or injured do not see
the LHW, LHWs are nevertheless an important source of consultation. In Balochistan, less
than a fifth (18 percent) of individuals who were ill or injured in the previous fourteen days
consulted the LHW if they consulted anyone at all. Nationally, 17 percent consulted their
LHW if they consulted anyone at all, a figure which has reduced compared to 2000 (19
percent).
Across the board, the main reason why LHWs were not consulted – for children under five, at
least – was that they felt that consultation was not necessary. A fifth felt that the LHW was
not available or was not helpful, down from 37 percent in 2000. However, this is a problem
that better supervision and training ought to be able to address. When the lack of medicines
is added to this, over a third of the reasons given for not taking up the service are due to
factors that the programme should be able to improve in order to increase the uptake of
curative services.
When the LHW is consulted, she usually provides the expected ‘first contact’ service. In most
of the cases where the LHW was consulted for children under five with diarrhoea or
respiratory infections, she was the first service provider consulted.
Some 22 percent of mothers with children under five, consulted their LHW about a
respiratory infection in the past fortnight, compared to 18 percent in 2000. In the case of
8
diarrhoea, the level of consultation was slightly lower, although there was a similar slight
improvement since 2000. Given that there are a number of other sources of care available,
this level of use indicates some confidence in the LHW on behalf of the households served.
As would be expected, female members of a household are more likely than males to consult
with the LHWs.
As found in the 3rd Evaluation, curative services remain an important part of the LHWs’ work.
Treatment of fever and diarrhoea were the most commonly reported activities (excluding
‘other’).
Table 2.1 Consulting the Lady Health Worker for illness or injury, by
province
Measure Punjab Sindh NWFP Balochistan AJK &

& ICT FANAs
% of individuals who were ill or injured in 21 12 12 18 27
the previous 14 days who consulted the
LHW – if they consulted anyone at all
LHWs were also asked to report on the last emergency case seen – that is, the last case that
they saw who required immediate referral to a health facility or hospital. Throughout the
country, 35 percent had never seen such a case, up from 20 percent in 2000. This might
reflect increased access to other providers in emergencies. For those who had seen an
emergency case, complications of delivery and pregnancy together with severe dehydration,
were the most common. This may reflect the community’s awareness of her role and
services.
A small proportion of LHWs appear to be charging a consultation fee to see sick children.
This is against Programme policy. The only provision for which charges are permitted is for
oral contraceptive pills and for condoms. Nationally, respondents stated that they paid the
LHW in 9 percent of consultations for diarrhoea.
2.3 Activities in the community

The LHW is responsible for mobilising the community to promote and improve health through
her participation in the village health committee (male) and in the women’s health committee.
There has been a significant increase in activity of health committees since the previous
evaluation.
In the 4th Evaluation, Balochistan has 92 percent of communities with women’s health
committees, the second highest proportion after Punjab, half of which met in the last month.
NWFP has the lowest proportion of communities with women’s health committees with 81
percent (Figure 2.2)
9
Figure 2.2 Activity and meetings of women’s health committees, by province
100
90
80
70
Percentage
60
50
40
30
20
10
0
Balochista
Punajb Sindh NWFP AJK/FANA National
n
women's health committee 93 90 81 92 87 91
met within the past month 95 63 80 50 64 83
undertaken activity in past yea 84 70 92 69 54 80
There is also a positive perception of the work of most LHWs. In Balochistan 91 percent of
respondents reported that the LHW has generally improved peoples' lives in the communities
and over two thirds reported that once the women had become an LHW, she was usually
respected.
2.4 Referral to health facilities

One objective of the LHWP was to improve the utilisation of public health facilities through
client referrals. Private facilities are often not accessible in rural areas or are too expensive
for the poor to afford. Adequate publicly provided services that are either free or cheap at the
point of delivery are therefore an important part of improving community health. However, for
emergency cases, the programme policy is now to refer to wherever the most appropriate
place is for treatment.
The LHW was asked to where she had referred her last acute case (Figure 2.3). Referrals
tend to be dispersed fairly evenly between the LHWs own facility, the government hospital
and private hospitals or clinic. In the previous evaluation, a half of these referrals were to the
LHWs own health facility. This has fallen to a third. Referrals to private providers, has risen
from nearly a quarter of all referrals in 2000, to nearly a third in 2008.
There are differences throughout the country. Particularly in Balochistan, the LHW is more
likely to refer to a private hospital/clinic (39 percent of all referrals) than her own health
facility. Similar results were found in Sindh and Punjab. However, in NWFP the referrals tend
to be to the LHW’s health facility, government hospital or another primary health facility. In
AJK/FANA, the referrals are typically to her health facility, then to a private hospital or clinic.
Clearly variations in the type of facility to which cases are referred will depend greatly on the
availability of the various facilities across the different provinces and their accessibility.
10
Figure 2.3 Place of referral of last acute case by LHW in Balochistan
Nearly two thirds of LHWs had used a referral slip with their last acute case in Balochistan:
this is the highest among all the provinces and higher than the national average of 42
percent (Table 2.2). Ninety two per cent of LHWs in Balochistan reported that patients went
to the facility they had been referred to. Some 83 percent of LHWs (compared to 78 percent
overall) reported receiving information including feedback slips from the health facility,
though this was significantly less for Sindh with 70 percent and AJK/FANA with only 56
percent.
Table 2.2 Comparison on LHW reports on referrals to health facilities
Punjab Sindh NWFP Balochistan AJK/FANA Overall

% LHWs filled referral slip 45 27 52 62 19 42
% LHW reported that patient 75 94 94 92 92 85
went to facility
% LHWs accompanied the 51 32 28 22 0 38
patient to health facility
% LHWs received some 83 70 89 83 55 79
feedback from health facility
Unfortunately, nationwide, staffing and supplies at the health facilities to which the LHWs are
attached are often very poor and some of the communities where LHWs work are under-
served by vaccination services.7 Similar problems were identified in the 3rd Evaluation and
would be expected to limit the effectiveness of the LHWs’ referral role. It is recognised that
this is an area where it is difficult for the Programme by itself to institute change.
2.5 Contribution to National Immunisation Days (NIDS)

As part of an international campaign to eliminate polio, Pakistan holds National Immunisation
Days. LHWs are important to the campaign because they provide access to homes in their
7
See the Quantitative Survey Report for information on services at health facilities.
11
catchment area which gives the opportunity for children under the age of six months to be
immunised. LHWs are supposed to be paid Rs.150 per day by the organisers of the Polio
Campaign.
The results from the survey show only 37 percent of LHWs in Balochistan have worked on
National Immunisation Days or Sub-National Immunisation Days (NIDS) in the past three
months (compared to 81 percent nationally).
Some 68 percent of those LHWs working on NIDs in the Balochistan had worked outside of
their catchment area (see Table C.2 in Annex C). Those LHWs in the Balochistan who had
worked on NIDs had done so for an average of nine days. Almost all of LHWs working on
NIDs in the Balochistan (95 percent) reported receiving extra payment, compared to 78
percent nationwide.
Figure 2.4 Participation of LHWs in NIDS in the past three months
12
2.6 Key points

• Throughout the country over eighty million people are receiving services from the
LHW, up from around 30 million at the time of the previous evaluation;
• Overall the services the LHWP has been providing are having a positive impact on
health amongst the poor and particularly women and children. LHWs are contributing
directly to higher levels of contraceptive use, iron supplementation, antenatal care,
neo-natal checkups and vaccinations amongst their clients;
• The level of service varies according to the type of service. However, in Balochistan
the proportion of clients receiving preventive and promotive services has increased
since 2000. Nevertheless, there remains a large group who are unserved and whom
the Programme must aim to reach;
• In Balochistan client communities continue to have a positive perception of their
LHW, and the activity of health committees seems to have increased substantially;
• The results from the survey showed that overall 37 percent of LHWs in Balochistan
have worked on NIDs in the past three months, for an average of nine days. Some 68
percent of these worked outside of their catchment area; and
• Almost all of those LHWs working on NIDs in Balochistan received extra payment (95
percent).
13
Levels of performance
3 Levels of performance
3.1 Performance of Lady Health Workers in service delivery

The performance measure of LHW service delivery described in the previous chapter is
based on a selection of ten preventive services. These cover LHW activities in, hygiene,
health education, vaccination promotion, family planning, pregnancy and birth, child nutrition
and growth monitoring8. As in the previous evaluation, this performance score can be used to
distinguish better and worse performing LHWs. The top 25 percent – the High Performers
provide significantly more services than the bottom 25 percent – the Poor Performers. In
between we have the Good Performers and those who are Below Average.
On our performance measure, the poor performers are on average only providing services to
26 percent of their eligible clients. By comparison, High Performers provide services to 78
percent (Figure 3.1)
Overall service delivery, as measured by the proportion of expected services being delivered
to eligible clients, has improved in all categories since 2000. Poor performers previously only
provided services to 17 percent of their eligible clients and High Performers provided
services to 68 percent.
Figure 3.1 Comparing Lady Health Worker provision of service by

performance category between 2000 and 2008
Source: Quantitative Survey Report 2000 and 2008.
It is easy to distinguish Poor Performers because they fail to deliver across the whole range
of services whereas High Performers cover nearly 80 percent of clients9 – and often well
above this for all services, except growth monitoring.10 In other words, performance appears
8
See Annex D for specific details
9
See Annex E for more information on different levels of performance amongst Lady Health Workers.
10 rd
As in the 3 Evaluation, the low level of growth monitoring even in the relatively high performing LHWs
suggests that there continue to be specific problems that need to be addressed if the Programme considers it
important to offer this service. This service level is even lower than the previous evaluation.
15
to be linked across different services, indicating that specialisation is not taking place. This is
consistent with the previous evaluation. High Performing LHWs are also working longer
hours, score higher on the knowledge test, and the households registered with them are
more likely to have been visited by the LHW in the past three months.
In Balochistan 17 percent of LHWs are in the high performing category and 24 percent are
Poor Performers (Figure 3.2). Note that over the entire (national) sample each category
contains 25 percent of LHWs by design.
While there have been improvements amongst all categories, the challenge for the LHWP
managers’ remains to further improve the performance of the Poor and Below Average
Performers.
Figure 3.2 Proportion of Balochistan Lady Health Workers in each

performance category
3.2 Explaining high performance

What are the key factors that the programme can use to improve performance?11 The
evaluation investigated the determinants of this performance in the entire (national) sample.
A number of factors are positively linked to performance, including LHW-specific factors
(experience, hours worked, training and supervision received), district level factors, and
community factors (such as the existence of women’s health committees). However, some
factors which might be expected to be significant were not found to be so, including LHWs
having another paid job, non-residency, LHS having access to vehicles and also the
knowledge score of the LHW.
The statistical analysis identifies a range of factors which help to explain these variations,
some of which are within the control of the programme and which therefore provides some
clear policy implications. Specifically, efforts should be made to:
11
A model was constructed and regression methods used to show the variables, which have the strongest
relationship with performance. For a full description of the model and techniques used see the Quantitative
Survey Report.
16
Levels of performance

• Ensure LHWs are working the full hours required of them – this requires adequate
supervision support. The number of hours LHWs in Balochistan are working per week
is lowest and close to half of the national average;
• Ensure that LHW supervisors are themselves regularly and effectively supervised by
the FPO and that performance monitoring tools such as the diaries and work plans
continue to be used.
• Encourage women’s health committees to be established/maintained in all served
areas. Maintain a focus on MIS reporting – in particular, making clear the services
that the LHW should be providing, and that LHWs understand their performance in
delivering these services is being monitored;
• Encourage DPIU’s to instigate effective LHW performance management regimes with
effective procedures for reporting and sanctioning LHW non-performance. Punishing
LHWs with salary deductions or delays does not appear to be an effective response
to non-performance, in contrast to providing additional training, ideally directed at the
specific area of non-performance;
overseeing LHWP activities.
3.3 Key points

• As was found in the 3rd Evaluation, there continues to be a marked variation in
service delivery amongst LHWs between High Performers and Poor Performers. High
Performers cover nearly 80 percent of their clients and the Poor Performers provide a
significantly lower level of service, covering only a quarter of their eligible clients.
There has been some improvement in service provision by all categories, however.
• In Balochistan 17 percent of LHWs are in the High Performers, and 24 percent are
Poor Performers.
• The ability of the Programme to target and deal with non-performance needs to be
increased. This should include strengthening LHW support and supervision systems
at a number of points: the LHW’s supervisor, at her health facility, in the community
through the health committees, and at district level.
17
The Lady Health Worker workload
4 The Lady Health Worker workload
4.1 Client registration

LHWs are supposed to serve a population of 1,000 individuals or approximately 200
households.
In Balochistan each LHW serves 86 households registered.12 This figure is much lower than
the national average, where each LHW registers 131 households (down from 145 in 2000).
However, the number of individuals served is a more important indicator of population
covered. Based on LHWs’ own reports, in Balochistan the average number of individuals
registered is 636 (Figure 4.1), which is also much lower than the national average.
Despite being contrary to programme norms, variations in the number of households per
LHW could be appropriate if they reflect relative ease of access and transportation feasibility
and other factors that affect registration and other service parameters. In fact the “one size
fits all” policy might usefully be examined with a view to developing different norms and
standards for different parts of the country, based on factors such as the degree of difficulty
in providing LHW services.
In every province there are fewer people registered on average by LHWs, than in 2000. The
national average has reduced from 980 in 2000 to 919 in 2008.
Figure 4.1 Average number of persons registered with the LHWs
1200
Number of persons registered
1000
800
600
400
200
0
Punjab/ICT Sindh NWFP (FATA) Balochistan AJK/FANA
2000/01 1062 898 952 723 855

2008 993 870 917 636 797
The minimum population for a catchment area of an LHW is 700 people. In Balochistan, 64
percent of LHWs had less than 700 people registered. The standard for client registration not
met.
In addition to recording the numbers of people that the LHW reported having registered, the
survey team checked a sample of her households from her register. The households were
12
See Annex F for information on LHW activities and population coverage.
19
asked if they knew they were registered with their LHW. In Balochistan and NWFP they all
did. In the other provinces there was a small proportion of households (around 5 percent),
who did not know they were registered with their LHW, suggesting that they were not being
served at all by the LHW.
4.2 Time spent working

On average, LHWs work 30 hours a week, up from 20 hours a week in 2000. This is a
reasonable week’s work of five hours a day over a six day working week, and meets the
Programme’s expectation. In Balochistan this falls to 17 hours a week, only 2 hours more
than the LHW was working previously (Figure 4.2), although part of this is due to increased
time spent on NIDS (see the discussion below).
In Balochistan 82 percent of LHWs reported working at least one day in the previous week
which lowest among all provinces. Nationally 4 percent reported not working at all in the
previous week. A variety of reasons were given including taking leave, illness and Eid
holidays.
Figure 4.2 Comparison of the number of hours worked last week by LHWs
Number of hours worked last week
40
30
20
10
0
Punjab/ICT Sindh NWFP Balochistan AJK/FANA
2000/01 23 14 23 15 21
2008 33 25 32 17 27
Nearly half of the LHWs reported working seven days in the week prior to the survey, which
is contrary to the Programme policy. Field visits by the evaluation team to LHWs confirmed
this was happening and that it was being reinforced with monitoring by the LHSs. A fifth of
LHWs in Balochistan reported working seven days in the previous week.
20
Figure 4.3 Number of days worked by the LHW in the previous week, by
province
100
80
Percentage of LHWs
60
40 Six days
Seven days
20
0
Six days 26 44 48 43 31
Seven days 59 25 35 20 35
In Balochistan, reflecting what is happening nationally, the activity taking up the largest
portion of an LHW’s time is visiting households, followed by working on NIDs (Figure 4.4).
On average, LHWs had spent seven hours participating in NIDS in the previous week. Once
a LHW is working outside her catchment area, even in providing a public health service,
should it still be considered a part of her core service provision? The programme might
consider how much time it is appropriate for LHWs to spend on NIDs, in the light of other
service requirements.
21
Figure 4.4 Allocation of work time by Lady Health Workers in Balochistan
Other, 3%
Health NIDs, 13%
Committees, 1%
Individual
meeting with LHS,
1%
MIS activities, 6%
Monthly
meetings, 3%
Going with
referral case, 1% Household visits,
Health House 67%
patients, 4%
Source: OPM LHWP Fourth Independent Evaluation, Quantitative Survey Data (2008).
4.3 Household visits made and clients seen

Some 19 percent of households in Balochistan had not received a visit from their LHW in the
past three months, compared to the national average of 15 percent.
The number of household visits reported by the LHW is highest in Punjab/ICT, and it has
increased slightly in all provinces since 2000 with the exception of NWFP, where there has
been a decrease (Figure 4.5). The overall average number of household visits was 27 per
week. Given that the average number of households registered with the LHW is now 131,
she would only need to visit fifteen households per week to achieve the programme standard
of visiting all households at least once in two months. However, community distances and
consequently travel time involved may impeded the attainment of this programme standard
in Balochistan.
22
Figure 4.5 Average number of household visits made last week by Lady
Health Worker
Number of household visits last week
35
30
25
20
15
10
5
0
NWFP
Punjab/ICT Sindh Balochistan AJK/FANA
(FATA)
2000/01 30 16 27 14 21
2008 32 20 24 15 24
Source: OPM LHWP Quantitative Survey Data 2000 and 2008.
The LHWs were also asked how many patients/clients they saw in the week preceding the
survey including those to whom they only gave advice. In Balochistan the average was 9
clients (Figure 4.6). In Balochistan, 79 percent of LHWs had seen less than ten clients in the
past week.
Figure 4.6 Average number of clients seen last week by Lady Health Worker
30
Number of patients/clients seen last week
25
20
15
10
0
Number of 25 16 23 9 24
patients/clients
Source: OPM LHWP Quantitative Survey Data (2008).
23
4.4 Taking on additional paid work

The proportion of LHWs who report having other paid work has declined in all provinces
(Figure 4.7), but remains highest in Sindh. In Balochistan only 4 percent of LHWs had
another paid job.
Although the percentage of LHWs with other paid jobs is significantly less than in 2000, in
undertaking other paid employment LHWs are not complying with programme policy.
However, the statistical analysis of the factors associated with high performance, suggest
that once other factors are accounted for, having additional paid work does not affect LHW
performance, although there may be other policy objectives that could be put at risk by some
forms of employment.
Figure 4.7 Proportion of Lady Health Workers with another paid job
4.5 Key points

• The LHWs in Balochistan have registered less households and clients than the
national average. The number registered has declined since 2000, reflecting the
national trend. Around 19 percent of LHWs’ households in Balochistan had not
received a visit in the past three months. At the time of the survey, 82 percent of
LHWs in Balochistan reported working in the previous week;
• Overall 44 percent of LHWs are working seven days a week. Whilst this falls to 20
percent in Balochistan this is not good practice;
• LHWs throughout the country spend most of their time in household visits, followed
by participating in NIDs; and
• The proportion of LHWs with another paid job has declined substantially since 2000.
In Balochistan, it is only 4 percent.
24
Knowledge, skills and training of Lady Health Workers and their supervisors
5 Knowledge, skills and training of Lady Health Workers

and their supervisors
5.1 The knowledge test

LHWs and their supervisors were tested using the ‘knowledge test’.13 The knowledge test is
divided into two sections:
•General questions covering a range of preventive and curative health care issues;
and
• Case histories where the problem must be identified and responded to with the
treatment or advice that would be provided to the patient.
A knowledge score was arrived at on the basis of how many questions were answered
correctly. The score is the percentage of correct answers given out of the total number of
questions.14 For purposes of comparison, exactly the same test that was applied in the
previous evaluation was also used in the current one.
5.1.1 Knowledge test results
The average score for LHWs in Balochistan was 64 percent. LHWs in NWFP have the
highest average score of 78 percent, and the largest improvement since 2000 (Figure 5.1).
As was the case in the previous evaluation, LHWs in Balochistan again had consistently
lower scores than their counterparts in other areas. Nevertheless, there was a significant
improvement in the knowledge score in all provinces compared with 2000.
Nationally, the overall mean score was 74 percent – an improvement on the mean score of
69 percent in 2000. There was some variation in the score between LHWs, although some
90 percent of LHWs scored between 60 and 90 percent of the possible total. Around 8
percent of LHWs scored below 60 percent; less than 3 percent of LHWs scored less than 50
percent.
LHSs’ knowledge scores have also increased. The national average LHS knowledge score
was 78 percent, compared to 74 percent in 2000. The LHS knowledge scores cannot be
analysed by province because the sample sizes are too small.
13
This is a test developed by the Evaluation team to assess LHWs and LHSs work-related knowledge and skills.
14
See the Quantitative Survey Report for further information on the knowledge test and the results.
25
Figure 5.1 Knowledge score for Lady Health Workers (2000 and 2008)
Percentage knowledge score
90
70
2000/01
50
2008
30
Punjab NWFP Balochist
Sindh AJK/FANA
and ICT and an
2000/01 70 71 67 60 69
2008 73 74 78 64 77
5.1.2 Analysing the results
There has been some improvement in the level of in depth knowledge, as is shown by the
large number of LHWs able to provide multiple correct responses.15
There were some specific areas of weakness in Balochistan. Knowledge of the vaccination
schedule is poor.. Less than a third of the Balochistan LHWs were able to name all four
vaccines, provide correct doses and also the correct ages for each dose.
There are serious deficiencies in the ability of LHWs to provide the correct doses of
medicines required in basic situations, as was found in the 3rd Evaluation. None of the LHWs
in Balochistan were able to provide the correct dose of Chloroquine to a child with symptoms
of malaria, even though they were encouraged to use the Programme manual or medicine
box to answer the question. The knowledge of LHWs and LHS about HIV transmission has
improved substantially, though less than two third of LHWs in Balochistan could give three or
more correct responses on how HIV is transmitted.
LHW performance in Balochistan was not good on the case history-based questions. Only a
third of LHWs were able to provide the correct weight of a normal/moderately malnourished
child, and just 30 percent for a severely malnourished child, according to the growth card
The knowledge of LHWs in Balochistan on the identification and management of pneumonia

is consistently lower than the national level. Less than half of the LHWs were able to identify
severe pneumonia in Balochistan. Of the LHWs who stated that they will give a full course of
Cotrimoxazole to a child in case of pneumonia, a mere 7 percent of LHWs were able to
provide a correct dose and duration of Cotrimoxazole.
More than three quarters of LHWs in the province were able to identify anaemia, and stated
that they would prescribe iron tablets to anaemic patients. Over half of the LHWs in
Balochistan stated that they would advise the patients to eat iron containing diet.
15
See Annex G for the knowledge test results.
26
Furthermore, 28 percent of LHWs said they would advise the patient to rest, which was more
than the national level.
Although the knowledge levels of LHWs in Balochistan have generally improved, further
improvements are required to avoid serious clinical consequences to their clients.
5.2 Improving knowledge through training

The level of clinical knowledge of LHWs and their supervisors is important in the provision of
a professional and safe service and for the reputation of the LHWP.
The training system has produced sufficient number of trainers to ensure that all LHWs have
completed their initial training. At the district level, a half of the EDO-Hs, nearly three
quarters of the District Coordinators and four out of five of the Assistant District Coordinators
are master trainers.
LHWs across the country are receiving their core training.16 Doctors at the health facility have
been important in the provision of the training along with the Lady Health Visitor and
Dispensers. Dispensers are being used less than in 2000.17
LHWs have completed their training, but it appears that not all of them had a female trainer.
In Balochistan only 8 percent of LHWs reported not having been trained by either a female
medical officer, a Lady Health Visitor or a female medical technician compared to nearly to a
fifth nationally.
Sindh had the highest proportion of LHWs who were not trained by either a female medical
doctor, a Lady Health Visitor or a female medical technician (Table 5.1). The Programme
also appears to have difficulty in providing female trainers in AJK/FANA. While it is not
common practice, in some instances Districts have used LHSs to conduct initial training.
Table 5.1 Percentage of LHW training that was provided by at least one
female trainer

% with at least one 90 55 96 92 80 81
female trainer
% not trained by either a 10 46 4 8 20 19
LHV, a female doctor or
a female medical
technician
Refresher and on-the-job training needs to be readily available in order to maintain and
update knowledge. The Programme has put enormous effort into developing and conducting
refresher training for all LHWs (Figure 5.2 and Table 5.2). In Balochistan nearly 90 percent of
LHWs report receiving on-the-job training from their supervisor.
The improvement in the average knowledge score reflects some success. However, there
remain substantial gaps in LHWs’ knowledge across the country. This problem was identified
16
The standard is three months basic training and twelve months task-based.
17
See Annex I for more information on training of LHWs (I.1) and their supervisors (I.2).
27
in the 3rd Evaluation, and although knowledge levels have improved, it appears that more
needs to be done to strengthen the initial and subsequent training processes.
Figure 5.2 Percentage LHWs who have received on the job training in the
past year and training at their last monthly meeting, by province
100
80
Percentage
60
40
20
0
Punjab/I Balochist
Sindh NWFP AJK/FANA
CT an
on the job training in 72 80 90 89 19
the past year"
training at last 34 44 42 33 21
monthly meeting
Table 5.2 Type of refresher training received by LHW in the previous year,
by province

Child health 83 85 88 59 38 81
Injection 71 57 55 35 68 63
contraceptives
Revised MIS 44 51 49 17 50 45
tools
OBSI/family 70 71 76 69 69 71
planning
Counselling cards 70 82 77 72 37 73
Food and 18 15 26 17 2 18
nutrition
5.3 Explaining LHW knowledge levels

Statistical techniques were used to evaluate what factors show the strongest relationship
with LHW knowledge scores, taking into account the effect of other variables. The potential
explanatory factors can be split into various groups: LHW characteristics; the characteristics
of the LHW’s supervisor; the characteristics of the community served by the LHW; and
district level factors.
The results show that LHWs who are more experienced and/or more educated tend to have
higher knowledge scores. LHWs that are currently married will, all else equal, have higher
28
knowledge scores. A possible interpretation of this is that married LHWs are more likely to
have gathered knowledge and skills from personal experience.
Knowledge scores are considerably lower amongst LHWs whose household’s main source
of income is agricultural wage earnings, suggesting that LHWs from poorer households will
have lower knowledge levels. This is also suggested by the finding that LHWs serving
communities with poor road access have lower knowledge levels.
Refresher training does not appear to have had an effect on LHW knowledge levels in
general, although those LHWs with a Counselling Cards Refresher Training manual
(received during refresher training) do have considerably higher knowledge scores.
Knowledge levels are higher for LHWs who received Continuing Education Training at the
last monthly meeting at the health facility, and also for those who have attended additional
Food and Nutrition training in the past year, perhaps because this is an area of particular
weakness. LHWs that produced a monthly plan for the previous month tend to have much
higher knowledge scores.
In terms of the impact of LHS and DPIU supervision and support, it appears that those LHWs
with more knowledgeable supervisors have higher knowledge scores. Furthermore LHWs in
districts where all served facilities have a specific individual with responsibility for overseeing
LHWP activities also have higher knowledge scores.
These results have some clear policy implications for programme. Specifically, efforts should
be made to:
1. Retain experienced LHWs;

2. Strive to ensure new LHW recruits have high levels of education. Since this is often at
odds with efforts to increase coverage (remaining unserved areas tend to have fewer
educated women), this may require innovative approaches. A greater proportion of LHWs
in Balochistan have Matric level education or higher than at national level;
3. Maintain and improve the frequency and quality of refresher training courses. Current
training courses should be reviewed to ensure they focus on areas where LHW
knowledge is weakest (e.g. growth monitoring, diarrhoea treatment, pneumonia). The
proportion of LHWs reporting attending each of the Refreshing Training courses in
Balochistan is generally higher than the national average;
4. Make efforts to monitor and maintain the LHWs’ supervisors’ knowledge levels. LHSs
who are older, more experienced and received all the required training tend to have
higher knowledge levels; and
5. Ensure all served health facilities have an individual with overall responsibility for
overseeing LHWP activities, and that within each district regular meetings are held
between these individuals and the DPIU.
29
5.4 Key points

• The knowledge score has increased since the previous evaluation for LHWs,
nationally.
• In Balochistan, however, there are specific areas of weaknesses. Knowledge of
vaccination schedule is poor; none of the LHWs were able to provide the correct dose
of Chloroquine to a child with symptoms of malaria
• LHS knowledge has also increased nationally;
• There has been some improvement in the level of in depth knowledge, as is shown
by the large number of LHWs able to provide multiple correct responses. However,
there are still areas where clinical knowledge needs to be improved for patient safety
and treatment. The Programme must therefore continue to aim to increase the
knowledge of both LHWs and their supervisors;
• The Programme has been successful in ensuring LHWs and supervisors attended
core-training programmes. The Programme now has an extensive programme of
refresher training that is reaching LHWs nationwide. Attention must be paid to ensure
that it effectively imparting the full range of knowledge that LHWs require; and
• As found in the previous evaluation the level of education of Lady Health Workers
and supervisors is correlated with their knowledge score. The higher the education,
the higher the score. It is important that the Programme does not lower its education
criteria if it wants to maintain performance.
30
Supervision of Lady Health Workers
6 Supervision of Lady Health Workers
6.1 Managing performance through supervision

Supervision is one of the most important levers the programme has for improving
performance. Supervisors should meet at least once a month with the LHW in her community
and ideally meet with client households both with, and without the LHW. These meetings
provide the opportunity to monitor the quality of the LHWs service delivery and her
knowledge, and to support good work-planning. The LHW should also attend a monthly
meeting at her local health facility where she can replenish her kit and may receive additional
training.
The LHS receives her supervision from the District Co-ordinator and the Assistant District
Coordinator (ADC). She should attend a monthly meeting at the District Programme
Implementation Unit (DPIU) where she reports on the past month’s work and plans for the
following month. Both the LHW and the LHS may receive feedback from the Field
Programme Officer (FPO) who acts as an internal inspector and advisor, and from
Programme Management.
6.2 Supervision of Lady Health Workers

Nationwide, nearly all LHWs now have supervisors. Given the importance of supervision to
the Programme, and the identification of a lack of supervisors as a significant problem in the
3rd Evaluation, this is an important achievement.
The intention of the programme was that each supervisor would be responsible for the
supervision of twenty-five LHWs. The national average is 23, which has come down from 28
in 2000. Supervisory responsibilities have therefore become better spread across
supervisors.
The percentage of LHWs who reported that they met their supervisors in the last 30 days has
increased nationwide. In Balochistan 49 percent of LHWs had had a supervision meeting
with their supervisors in the last month, compared to 44 percent in 2000. However there was
a sharp decline in AJK/FANA where only 50 percent of LHWs reported a visit by LHS in the
last month, compared to 73 percent in 2000 (Figure 6.1).
The LHS checklist is used to inspect the LHW’s level of service delivery and check her
knowledge. A high proportion of LHSs are using their performance checklists when
supervising the LHWs. There are variations in actual practices between provinces, with LHSs
in NWFP and AJK/FANA being more likely to use the checklist (Figure 6.2).
Just under two thirds of LHWs in Balochistan reported that the LHS had used this checklist in
her previous supervision visit. Of these, nearly half had informed the LHW of her score.
31
Figure 6.1 Percentage of Lady Health Workers visited by supervisor in the

past month for supervision
100
80
Percentage
60
40
20
0
NWFP Baloch‐
Punjab Sindh AJK/NA
(FATA) istan
2000/01 78 56 69 44 73
2008 84 78 81 49 50
Figure 6.2 Percentage of LHWs who reported the LHS using her checklist in
her previous supervision visit
100
90
80
70
Percentage
60
50
40
30
20
10
0
Baloch‐
Punjab Sindh NWFP AJK/NA
istan
LHW report that LHS 81 62 92 65 95
used checklist
A high proportion of LHWs in all provinces could produce reports for the previous month and
though only 58 percent of the LHWs in Balochistan could show a current work plan.18
Monthly meetings at the health facility are well attended. There has been an increase in
LHWs attending their monthly meeting since the previous evaluation.
18
See Annex K: Work planning and reporting.
32
Supervision of Lady Health Workers
Figure 6.3 Percentage of Lady Health Workers who have attended the
monthly meeting at their health facility in the past month
6.3 Transportation
In the original design of the programme, all supervisors were supposed to have access to
their own vehicle, a driver and an appropriate POL allowance. Transportation is essential for
supervisors for monitoring LHWs and visiting the health facilities and the community.
At the time of the 3rd Evaluation, there were substantial shortfalls in supervisors’ access to
vehicles and POL. Nationally, the situation has improved, with 72 percent of supervisors
usually or always having access to a programme vehicle compared with 64 percent in 2000.
However, problems remain. At the time of the survey, DPIU staff reported that, on average,
that over a quarter of their vehicles were non-operational.
The POL allowance is supposed to be a budget in litres rather than a set amount. This is not
happening. The POL allowance needs to be sufficient to enable the Lady Health supervisor
to visit all of her LHWs once a month as well as undertaking her additional responsibilities,
for example National Immunisation Days and transportation of supplies.
If a LHS did not have vehicle she used other forms of transport. However this incurs
expenses. The average cost for the previous month was Rs.1,730. This was paid by the LHS
and only 66 percent of them reported that it would be reimbursed. In addition, nationally, 62
percent of LHS were responsible for the repair of their vehicle and only 77 percent reported
being reimbursed for vehicle repairs.
33
6.4 Key points

• Nationally, there has been a reduction in the proportion of over-burdened
supervisors, which should allow for better supervision. The national average is 23
LHWs per LHS, down from 28 in 2000;
• There have been improvements in the level of supervision of LHWs in Balochistan
and nationally;
• There is a high level of attendance at the health facility monthly meeting. Most of the
LHWs have attended the monthly meeting at the health facility in the past month;
• Nationally, there has been an improvement in LHS access to Programme vehicles;
and
• The Lady Health supervisors across the country cannot be confident of receiving her
FTA or reimbursement for vehicle repairs.
34
Programme salary payment and medical supply systems
7 Programme salary payment and medical supply

systems
7.1 Performance of the pay system

LHW salaries are supposed to be paid monthly, directly into the LHW’s own bank account.
However, in Balochistan only 72 percent of LHWs had received their pay in the past three
months, compared to 96 percent in 2000 (Figure 7.1). Though, 5 percent of LHWs in
Balochistan had received less money than expected when they last received their salary
(Table 7.1) which is lower than the national average.
Figure 7.1 Percentage of LHWs paid within the past three months
Table 7.1 Proportion of Lady Heath Workers receiving less salary than
expected

% LHW received less salary 13 11 6 5 6 11
than expected when last paid
7.2 Supply of medicines and equipment

There are continuing problems in the supply of medicines and contraceptives for LHWs.
Comparing across provinces, Sindh has the largest problem with ‘stock outs’ of two months
or more, whilst Balochistan has the lowest occurrence at only 6.6 percent (Table 7.1).
Balochistan appears to have particular problems with the following items: Benzyl Benzoate,
Injectables, and Antiseptic Lotion.
35
In general, expired stock is not a big problem. If the LHW has the item in stock it appears to
be dispensed with a reasonable frequency.19
Table 7.2 Percentage of LHWs with stock outs for more than two months
Item Punjab Sindh NWFP Balochistan AJK/FANA

Paracetamol tablets 2.6 9.5 5.1 2.5 2.0
Paracetamol syrup 13.2 17.0 14.2 3.4 0.0
Chloroquine tablets 14.0 37.0 41.2 5.1 25.8
Chloroquine syrup 28.1 22.5 25.0 5.3 4.7
Mebendazole tablets 29.6 41.1 15.4 8.2 16.0
Piperazine syrup 17.8 14.5 14.7 9.7 21.7
Oral rehydration salts 14.3 8.7 5.8 6.2 0.0
Eye ointment 16.3 16.6 3.2 6.2 0.0
Cotrimoxazole syrup 28.4 11.4 23.2 8.3 1.4
Vitamin B complex syrup 4.3 10.5 3.9 3.0 0.0
Iron and folic acid tablets 8.4 38.6 17.8 2.1 6.1
Antiseptic Lotion 15.7 17.0 8.6 10.0 4.8
Benzyl Benzoate 8.1 15.0 5.1 9.1 6.3
Bandages (cotton) 10.2 12.7 7.7 8.1 9.4
Condoms 0.9 8.5 4.9 7.5 2.2
Injectables 17.6 39.8 15.0 18.2 40.8
Oral contraceptive pills 0.1 7.1 2.1 2.3 0.0
Average 13.5 18.7 12.0 6.6 8.0
Though most LHWs have the necessary equipment, only one third has a functional weighing
scale. The proportion of LHWs that have a functioning weighing scale is worryingly low in
Balochistan, at a mere 11 percent. Only 42 percent of LHWs in Balochistan have blank
growth monitoring cards. Lack of weighing scales means that the growth monitoring service
cannot be provided.
In general, LHWs in Balochistan are relatively less likely to have the required functional
equipment and administrative materials compared to LHWs in all other provinces.
Overall, it is clear that there remain significant problems in keeping LHWs supplied with all
the necessary equipment. The programme needs to both furnish the LHW’s kit when she
begins her job and ensure that items are replaced or kept up-to-date throughout her service.
7.3 Improving distribution and supply

Since 1999 the Programme has had a system of replenishment for LHW supplies. This
system is not working as effectively as it should. While purchasing is based on an annual
stock take, the long lead time for awarding tenders, receiving supplies, and having them
tested, means that either the purchasing and distribution process must be made a lot more
efficient or minimum stock levels need to be higher. The level of purchasing needs to be
19
See Quantitative Survey Report.
36
Programme salary payment and medical supply systems
better aligned to actual usage rates and this relates to budget requests. These problems are
for the FPIU to resolve with co-operation from the PPIU and DPIU.
Some 75 percent of DPIUs reported that they do not issue to facilities on the basis of their
demands; in other words the replenishment system is not operational. The LHS is often
taking the medicines from the DPIU to her facilities, after she has come into her monthly
meeting (not necessarily every month).
7.4 Key points

• In Balochistan only 72 percent of LHWs had received their pay in the past three
months, compared to 96 percent in 2000 (Figure 7.1). However, only 5 percent of
LHWs in Balochistan had received less money than expected when they last received
their salary;
• Nationally, there are continuing problems with the supply of medicines and
contraceptives. Numerous medicines had not been available for over two months.
Balochistan appears to have particular problems with the following items: Benzyl
Benzoate, Injectables, and Antiseptic Lotion;
• There are also still problems in the supply of equipment. In Balochistan, a mere 11
percent of the LHWs had weighing scales necessary for growth monitoring. LHWs in
Balochistan are also relatively less likely to have the required functional equipment
and administrative materials compared to LHWs in all other provinces; and
• Similar supply problems were identified in the previous evaluation. Unlike supervision
and knowledge, which both show some improvement, the supply problems have not
improved sufficiently. The Programme still needs to address this effectively.
37
Annexes
39
Annexes
Annex A The quantitative survey
The objective of the quantitative survey was to provide a nationally representative picture of
the functioning of the programme. Interviews were conducted with lady health workers; the
households that they serve; the communities where they work; the LHWs’ supervisors; and
the First Level Care Facilities (FLCFs) to which the LHWs are attached (‘served’ FLCFs).
This information provides a comprehensive picture of the work carried out by the LHWs and
of the functioning of the programme support services necessary to their work. Information
was collected on a set of unserved households in areas where the Programme does not
operate, to enable an assessment of the impact of the LHWs on the health status of the
population they serve. Information was also collected from health facilities and from the
community in these areas.
Altogether, 554 LHWs and 5,752 households were interviewed. The final sample sizes for
each type of interview used in the analysis are shown in Table A.1.
Table A.1 Sample breakdown by unit of observation
Unit of observation Area Province Total

LHW Unserved Punjab/ Sindh NWFP Baloch- AJK/
areas ICT istan FANA
Districts 19 12 9 10 7 57
Lady Health Workers 554 189 119 86 90 70 554
Households 4,378 1,374 1,864 1,925 853 978 762 5,752
First Level Health 267 68 116 71 52 51 45 335
Facilities (FLCFs)
Community interviews 486 86 178 132 73 105 84 572
Lady Health supervisors 298 96 73 45 45 39 298
The sample used five geographic strata, which were provinces or federally administered
areas: Punjab, Sindh, NWFP, Balochistan and AJK/FANA.20 The focus of this report is on the
performance of the programme as a whole, although some of the key estimates are also
presented by stratum. Separate reports have also been produced for each of the five strata.
Sampling weights were defined to allow the calculation of representative national and
provincial estimates. All estimated standard errors used in significance testing and in the
econometric modelling have been adjusted for sample clustering. More details on the
sampling methodology and the calculation of the survey weights are given in Annex A in the
main Quantitative Report.
In the first stage of sampling 60 districts were selected to be covered by the survey. Districts
assessed to be too insecure for fieldwork to be conducted safely were excluded from being
selected. In this way, nine of the 133 districts in existence in Pakistan in April 2008 were
excluded from the sample frame due to insecurity: two in North West Frontier Province
(NWFP) and the whole of the Federally Administered Tribal Areas (FATA). In addition, after
20
Note that two districts in NWFP and all seven districts in FATA were excluded from the sample frame in 2008
due to high levels of insecurity.
41
the district sample was drawn, three of the selected NWFP districts were dropped, also due
to insecurity. So the final number of districts covered by the evaluation is 57.
In each selected district a sample of served health facilities (i.e. those with LHWs attached)
was drawn from the programme database.21 LHWs were then sampled from these facilities.
LHWs were included in the sample if they had completed their initial three months training.22
Households were sampled from the selected LHWs’ registers. The supervisor of each
selected LHW was interviewed; community interviews were also conducted for each LHW
sampled.
A different sampling scheme was used for the unserved population. One or two FLCFs not
attached to the LHWP (‘unserved’ FLCFs) were sampled in each of the 60 selected districts.
Since it was not possible to get a reliable national list of all unserved health facilities, these
were identified in each of the sampled districts with the help of District Coordinators of the
programme. For each sampled unserved FLCF, the in-charge of the health facility was
consulted to assist the field-teams in dividing the FLCF catchment area into small territorial
segments. The segmentation was designed so as to mimic the partition of the area into the
territories of ‘virtual LHWs’ (see Annex A of the main Quantitative Report for details). At each
facility one segment was randomly selected. All households were listed in the selected
segments and a sample of unserved households was randomly selected for interview.
Fieldwork was conducted between July and November 2008. Losses were generally low.
The largest problem of non-response was at the unserved FLCFs, where around 23 percent
of interviews with facility staff could not be undertaken (although households attached to
these FLCFs were interviewed in any case).
21
The sampling procedure was designed such that the served FLCF sample included a small panel of FLCFs that
rd
had been covered in the 3 Evaluation.
22
Note this is a difference from the design of the TIPE where only LHWs with at least three years’ experience
were covered by the evaluation.
42
Annexes
Annex B Demographic and educational characteristics of

LHWs
Table B.1 Demographic and educational characteristics of Lady Health

Workers
Characteristic National Punjab Sindh NWFP Balochistan AJK &

% & ICT % % % FANA
Age distribution (age groups)
15-19 1 1 0 2 3 0
20-24 13 7 16 20 30 10
25-29 25 19 21 42 44 29
30-34 27 29 33 20 7 32
35-39 16 20 12 7 11 16
40-44 9 12 7 6 4 12
45+ 9 12 10 2 3 2
Total* 100 100 100 100 100 100
Mean age now 32 34 32 29 28 32

Mean age when recruited 25 27 24 24 21 23
Marital status of the LHWs
Never married 26 19 27 47 35 16
Currently married 66 69 69 50 58 78
Widow/divorced/separated 9 12 5 3 7 7
Years LHW has resided in
village/mohalla
0-2 4 4 4 2 0 4
3-4 8 6 5 7 1 0
5-20 31 34 32 31 13 31
More than 20 8 12 6 4 3 4
Since birth 52 45 54 56 83 61
Total 100 100 100 100 100 100
Non resident 3 0.9 11 0 2.1 2
Educational level
Less than 8th class 1 1 0 0 0 0
8th–9th class 36 40 36 24 30 28
th th
Matric (10 –11 ) 44 46 36 51 46 53
Intermediate 15 9 23 25 19 15
Graduate 4 5 5 0 6 4
Class certificate seen and
77 80 74 83 62 57
confirmed
Source: Quantitative Survey Report 2008. Note: All figures are per cent. * Due to rounding issues some totals do
not actually equal 100.
43
Annexes
Annex C Service delivery of Lady Health Workers, by

province
Service delivery by Lady Health Workers to four of their important target groups is shown in
Annex Table C.1. These are: households (as a unit); women who have had a birth in the
previous five years; married women aged 15–49; and children under three.
LHWs provide a range of promotive and preventive services to these groups. The Table
shows the extent to which LHWs in each of the provincial areas:
• Provide hygiene education on drinking water and sanitation;

• Provide nutritional advice and growth monitoring;
• Monitor and advise women on their health, and that of their babies, after birth;
• Supply and refer women for family planning;
• Motivate and educate women on family planning; and
• Promote and facilitate vaccination.
45
Table C.1 Lady Health Workers preventive and promotive services by

province
Measure National Punjab Sindh NWFP Balochistan AJK

average & ICT &
FANA
Households registered with the LHW

% who report that the LHW has ever talked 63 64 60 58 73 72
to them about ways to improve the
cleanliness of drinking water
% who report that the LHW has ever talked 64 63 66 61 72 72
to them about ways to improve hygiene and
reduce diarrhoea
Women who had a birth since 1997
(reporting on their last birth):
% who report that the LHW gave them 50 50 51 52 47 57
advice on which foods to eat while pregnant
% who report that the LHW came to see her 14 11 19 16 8 17
and the baby within 24 hours
% who report that the LHW came to see her 46 46 52 41 26 49
and the baby within 7 days
% LHWs who weighed the baby (of those 16 19 12 11 3 26
who came to see the baby within 7 days)*
% LHWs who gave advice on breastfeeding 31 30 36 30 16 36
(of those who came to see the baby within 7
days)*
% who report that the LHW gave her advice 50 52 47 48 52 42
on family planning within 3 months of the
birth
Currently married women (aged 15-49)
% of current users of modern contraceptives 41 39 31 56 68 23
who were supplied by the LHW
who were supplied or referred by the LHW
% of current users of pills and condoms who 74 78 59 75 84 48
were last supplied by the LHW
% of non-users of modern contraceptives 41 40 48 39 34 36
who have discussed family planning with the
LHW
% of non-users of modern contraceptives 21 21 25 21 10 18
who have discussed family planning with the
LHW in the last 6 months
who were not supplied or referred by the
LHW who have discussed family planning
with her
who were not supplied or referred by the
LHW who have discussed family planning
with her in the last 6 months
Children under age 3 years:
% whose mothers say that the LHW talked to 75 74 76 77 71 75
her about vaccinating the child
46
Annexes
Measure National Punjab Sindh NWFP Balochistan AJK

average & ICT &
FANA
% whose mothers say that the LHW 59 62 42 70 59 70

encouraged her to take the child for
vaccination at the age when it was
necessary
% whose mothers say that the LHW gave her 48 45 50 53 53 61
advice on feeding the child
% ever weighed by the LHW 21 26 12 15 5 31
% weighed by the LHW in the previous 3 11 15 5 8 0 15
months
Source: Quantitative Survey Report 2008. Note: * Excludes those where LHW was present at birth.
Table C.2 Lady Health Workers participation in National Immunisation Days

(NIDS)

% LHWs participated in NIDs 87 82 85 37 75 81
during last 3 months
% LHW reported that worked 69 50 40 68 59 60
outside catchment area
Mean number days participate 8 12 11 9 3 9
in NIDS
Of those who participated in 70 99 73 95 92 78
NIDS, % LHWs received
payment
47
Annexes
Annex D Creating a measure of performance for Lady

Health Workers
Households sampled from each LHW’s register were asked about the provision of a range of
services by the LHW. For each LHW, we construct a summary measure of LHW
performance which covers a range of the preventive services that all LHWs are supposed to
provide.
This summary LHW Performance score is exactly equivalent to that in the 3rd Evaluation. It
includes five broad categories of preventive and promotive services in the areas: hygiene
promotion, vaccination, family planning, pregnancy and birth, child nutrition and growth. For
each category two tasks were selected.
The ten measures included in the performance score are:
• Number of households who report that the LHW talked about ways to improve
cleanliness of water;
• Number of households who report that the LHW talked about ways to improve
hygiene;
• Number of women aged 15-49, who are non users of modern contraceptives, who
report that the LHW discussed family planning;
• Number of women aged 15-49, who are users of modern contraceptives, who report
that the LHW supplied them or referred them to a health centre;
• Number of mothers who gave birth in last 3 years who report that the LHW gave
advice on which foods to eat during pregnancy;
• Number of mothers who gave birth in last 3 years who report that the LHW saw
mother at birth or within a week of birth;
• Number of children under 3 years whose mothers report that the LHW talked about
vaccination;
• Number of children under 3 years whose mothers report that the LHW encouraged
vaccination of the child at appropriate ages;
• Number of children under 3 years whose mothers report that the LHW gave advice on
feeding the child; and
• Number of children under 3 years whose mothers report that the LHW weighed the
child within the last three months.
Most of these services are only relevant to particular groups. For example, in order to
evaluate a LHW’s performance on vaccination and weighing children under 3 years, we must
sum the total number of children under 3 years in the sample interviewed for that LHW. This
provides the denominator for the measure. The numerator is given by the number of those
children whose mothers were informed about vaccination, were encouraged to take their
child for vaccination at an appropriate age and the number who were weighed in the last
three months.23
In this way each LHW was evaluated on the basis of the people she should have served,
which vary across the LHWs. The summary performance measure was constructed by
23
To illustrate, suppose there were six children below three years in the sample of households interviewed for a
particular LHW. She weighed two in the last three months, and discussed vaccination for five and encouraged
vaccination for four. In other words, she was supposed to carry out 18 tasks (6 weightings + 6 discussions on
vaccination + 6 encouragements of vaccinations). Out of the 18 she has performed 2 + 5 + 4 = 11. Hence, a
simple score on these three tasks alone is 11/18.
49
summing the numerator and denominator in this manner across all of the services listed
above. The final proportion was then expressed as a percentage. It was decided not to
standardise for client group composition.
Curative services are excluded from this measure as they are carried out on demand and
may therefore reflect a more complex range of factors than the promotive services listed
above. Measures of activities, rather than services delivered, are also excluded. For
example, the number of hours worked, numbers of households visited etc. This is partly
because many of these measures are reported by the LHW herself, and therefore more likely
biased, whereas the service delivery measures are reported by the households.
50
Annexes
Annex E Levels of performance
Annex Table E.1 provides more detailed information on the difference between Poor
Performers and High Performers on ten services provided by the LHW.24 We can see from
the table that the Poor Performers (the bottom 25 percent of LHWs scored an average of 26
percent, and the High Performers (the top 25 percent of LHWs) scored and average of 78
percent. It is quite easy to distinguish Poor Performers from High Performers.
Table E.1 Different levels of performance amongst Lady Health Workers
Measure Lowest 2nd lowest 2nd best Best

quartile quartile quartile quartile
Mean summary performance score 26 49 63 78
% of households who report that LHW 34 64 74 88
talked about ways to improve cleanliness
of water
% of households who report that LHW 33 65 77 90
talked about ways to improve hygiene
% of women aged 15-49, who are non 24 36 49 63
users of modern contraceptives, who
report that LHW discussed family
planning
% of women aged 15-49, who are users 23 39 46 62
of modern contraceptives, who report
that LHW supplied them or referred them
to a health centre
% of mothers who gave birth since 2004 16 40 65 80
who report that LHW gave advice on
which foods to eat during pregnancy
% of mothers who gave birth since 2004 20 38 54 78
who report that the LHW saw mother at
birth or within a week
% of children < 3 yrs. whose mothers 47 74 88 98
report that the LHW talked about
vaccination
report that the LHW encouraged
vaccination at the correct age
report that the LHW gave advice on
feeding the child
report that the LHW weighed the child
within the last three months
Source: Quantitative Survey Report 2008. Note: * Excludes those where LHW was present at birth.
24
For further information see the Quantitative Survey Report.
51
Annexes
Annex F Lady Health Worker activities and population

coverage
Table F.1 Number of households and persons registered by Lady Health

Workers
Activity National Punjab/ Sind NWFP Baloch- AJK &

% ICT% h% % istan% FANA %
Number of households registered
Up to 50 1 0 0 0 10 0
51–100 17 4 25 22 63 42
101–150 54 53 62 68 22 48
151–200 26 40 13 10 6 11
201–250 2 4 0 0 1 2
Total 100 100 100 100 100 100
Mean number of households 131 150 117 118 86 108
registered with LHW
Number of persons registered
with the LHWs
Up to 500 3 0 2 0 29 6
501–700 6 1 5 10 35 14
701–900 33 22 51 38 25 58
901–1100 47 61 36 41 10 9
1101–1300 10 15 3 7 1 9
More than 1300 2 1 2 4 0 4
Total 100 100 100 100 100 100
Mean number of persons registered 919 993 870 917 636 797
with LHW
53
Table F.2 Number of hours Lady Health Workers worked last week by type
of activity
Activity National Punjab Sindh NWFP Balochistan AJK &

% / ICT % % % % FANA%
Total no. of hours LHW
worked last week
Less than 15 20 9 35 11 69 19
15–19 10 8 15 9 7 15
20–24 12 16 6 12 5 15
25–35 25 29 18 32 5 22
More than 35 33 38 26 36 14 29
Total 100 100 100 100 100 100
Average no. of hours/
activity
Household visits 14.0 16.0 9.1 15.4 11.4 18.0
Seeing patients at health
house 1.5 1.9 1.1 0.9 0.8 1.0
Accompanying referral
case 0.8 1.0 0.6 0.5 0.1 0.2
Monthly meeting 1.4 1.7 0.8 1.6 0.4 1.3
MIS activities 3.3 3.9 2.4 3.8 1.1 2.9
Meeting with LHS
individually excluding
monthly meeting 0.4 0.6 0.3 0.2 0.2 0.1
Meeting or working with
health committees 0.4 0.5 0.6 0.1 0.2 0.5
Participation in NIDS 6.8 6.4 9.1 8.4 1.9 1.9
Others 0.7 0.8 1.0 0.4 0.4 0.6
Total 29.5 32.9 25.1 31.7 16.6 26.8
Table F.3 Days worked by Lady Health Workers during last week
Measure National Punjab Sindh NWFP Balochistan AJK &

% & ICT % % % % FANA
%
Number of days, LHW
worked last week
Did not work at all 4 0 10 4 18 2
1–3 days 7 8 7 2 7 10
4–5 days 10 7 14 11 13 22
6–7 days 79 85 69 83 62 66
Total 100 100 100 100 100 100
Mean number of days worked 6 6.2 5.2 5.9 4.7 5.6
last week
Reasons for not working for
full week*
Taking leave 9 2 7 22 19 9
Sickness 32 16 44 41 42 22
54
Annexes
Measure National Punjab Sindh NWFP Balochistan AJK &

% & ICT % % % % FANA
%
Travelled out of 3 1 5 4 4 0
village/mohalla
Work completed /not enough 1 0 0 0 6 10
to do
Others 55 81 44 33 30 59
Total 100 100 100 100 100 100
Source: Quantitative Survey Report 2008. Note: * Full week means six days or more
55
Table F.4 Number of household visits made by the LHW and number of
clients seen during the past week as reported by the client
Measure National Punjab Sindh NWFP Balochistan AJK&

% & ICT % % % % FANA
%
Number of household visits
Up to 10 household visits 19 8 34 16 61 10
11–20 19 11 31 20 20 37
21–30 27 23 26 46 11 27
31–40 21 32 5 12 7 21
41–50 12 20 2 6 1 4
More than 50 household visits 3 5 2 0 0 0
Total 100 100 100 100 100 100
Mean number of household
visits made last week 26.8 32.3 19.7 23.9 14.5 23.6
Number of clients seen last
week
Up to 10 clients 29 17 41 23 79 18
11–25 37 36 46 38.5 19 42
26–50 31 41 13 34.8 3. 36
More than 50 clients 3 4 0 4.1 1 4
Total 100 100 100 100 100 100
Mean number of clients seen
last week 21.8 25.0 16.1 23.11 9.1 25.1
56
Annexes
Annex G The knowledge test
During their interviews LHWs and LHSs were asked a number of questions to test their
knowledge in areas important in the LHWs service delivery. The questions covered a range
of preventive and curative health care issues, hygiene and nutrition. They were also
presented with a number of hypothetical case histories where they were asked to identify the
problem and to respond with the treatment or advice they would provide the patient.
A Knowledge Score was arrived at on the basis of how many questions were answered
correctly. It is possible to score fifty-five points, twenty-eight for the general knowledge
section (Annex Table G.1) and twenty-seven points (Annex Table G.2) for the case studies.
The score is presented as a percentage of the highest possible score.
The scoring attempts to identify LHWs with sufficient, general knowledge as well as to
identify those LHWs with a depth of knowledge. For example, for questions with multiple
possible responses, one point was given if a LHW was able to provide one correct response,
and another point if she was able to provide three or more correct responses. The scoring
was as follows:
Table G.1 Scoring for general knowledge section of the knowledge test
Question Answer Points

Contraindications for oral contraceptive pill One correct answer 1
Three or more correct answers 1
Contraindications for IUD One correct answer 1
Three or more correct answers 1
Advice about breast feeding to mother of One correct answer 1
new born Three or more correct answers 1
How soon after birth should a mother start One point if response is less than 4 hours 1
breast-feeding her baby? after birth.
Should the mother feed to her baby the One point for ‘yes’ 1
colostrum?
At what age should a mother begin to One point for 4 to 6 months, or 4, 5 or 6 1
introduce semi-solid foods into her baby’s months.
diet?
Can you name the vaccine and dose for: One point for each correct answer
BCG? 1
DPT? 1
Polio? 1
Measles? 1
Can you name the correct age for doses of: One point for each correct answer
BCG? 1
DPT? 1
Polio? 1
Measles? 1
How would you advise a mother of a child One point for any one correct answer 1
with diarrhoea and mild dehydration if you One point for three or more correct answers 1
did not have ORS?
What advice if child will not take ORS? One point for any one correct answer 1
57

What advice to prevent diarrhoea? One point for any one correct answer 1
One point for three or more correct answers 1
How is malaria caught? One point for correct answer 1
What treatment and advice for a two-year One point if Chloroquine given 1
old child with symptoms of malaria? One point if Paracetamol given or advice to 1
reduce child’s temperature
One point for ‘refer to health facility 1
immediately- or if no improvement’
Name correct dose of Chloroquine for a One point for correct dose (1 teaspoon- one 1
child referred to health facility time)
How is HIV/AIDS transmitted? One point for any one correct answer 1
Total possible points for General 28
Knowledge Section
Table G.2 Scoring for case-based section of the knowledge test

Growth Monitoring
Case 1:
How much did the child weigh at four One point for 4.1 to 4.7 kilograms 1
months?
According to the card, what is the child’s One point for ‘normal to severely 1
nutritional status now? malnourished’
What does the card show about the child’s One point for stating that the child was 1
growth over the last four months? gaining weight/ growing adequately
Would this child need to be referred to a One point for ‘No’ 1
health facility?
Case 2:
How much did the child weigh at four One point for 3.7 to 4.2 kilograms 1
months?
According to the card, what is the child’s One point for severely malnourished 1
nutritional status now?
What does the card show about the child’s One point for stating that the child was 1
growth over the last four months? failing to gain weight
What extra information would you request One point if requested information about 1
if any? eating and feeding practices
Would this child need to be referred to a One point if requested information about 1
health facility? recent illnesses
One point for ‘Yes’ 1
Diarrhoea
Case 1:
What is the degree of dehydration of the One point for mild to moderate (some) 1
child? dehydration
What treatment and advice would you One point for rehydration (ORS or SSS) or 1
give? breast-feed more often.
One point if they advise to bring the child 1
back for reassessment soon or to seek
58
Annexes

help if the child does not improve.
Case 2:
What is the degree of dehydration of the One point for severe dehydration 1
child?
What treatment and advice would you One point for rehydration (ORS or SSS) or 1
give? to breastfeed more often
One point for referral to the health centre 1
Respiratory Infections
Case 1:
Does the child have a simple cough or One point for severe pneumonia 1
cold, pneumonia or severe pneumonia?
Would this child need to be referred to a One point for ‘yes’ 1
health facility?
What treatment and/or advice would you One point for Cotrimoxazole/antibiotics 1
give?
Case 2:
Does the child have a simple cough or One point for pneumonia 1
cold, pneumonia or severe pneumonia?
What treatment and/or advice would you One point for Cotrimoxazole/ antibiotics 1
give?
One point for giving fluids/ continuing 1
breastfeeding
Pregnancy
Case 1:
What is the woman’s problem? One point for ‘anaemia’ 1
What kind of examination is required and One point for examine ‘conjunctiva’ or ‘ask 1
what extra information would you request? about eating habits or recent illnesses’
What treatment and advice would you One point for ‘Fefan’ or ‘eating more iron- 1
give? rich foods’
Case 2:
What treatment or advice would you give? One point for referral to health centre 1
Would this referral be urgent? One point for ‘yes’ 1
Total possible points for Case-Based 27
Section
59
Annexes
Annex H The knowledge test results
The results for Lady Health Workers, both nationwide and for Balochistan are presented
below. These include the results for the general knowledge (Annex Table H.1) and the case
based results (Annex Table H.2)
Table H.1 The knowledge test-general knowledge section, percentage of

correct answers given by LHWs, nationally and in Balochistan
Measure LHWs (%)

Total Balochistan
Contraindications for the contraceptive pill
% giving at least one correct answer 92 98
% giving 3 or more correct answers 55 69
Contraindications for the IUD
% giving at least one correct answer 85 90
% giving 3 or more correct answers 11 17
Breastfeeding and nutrition
% stating that mothers should start breastfeeding within four hours of birth 97 92
% stating that weaning foods should be introduced at the age of 4-6 months 82 88
EPI vaccination schedule
% who could name all four vaccines (BCG, DPT, Polio, Measles) 94 78
% identifying all four vaccines and giving correct number of doses 91 72
% identifying all four vaccines and giving the number of doses and the
correct ages for each dose 72 31
Diarrhoea
% giving at least one correct answer to mother of child with diarrhoea and
mild dehydration, if lacking packets of ORS 100 97
% giving three or more correct answers to mother of child with diarrhoea
and mild dehydration, if lacking packets of ORS 57 43
% giving at least one correct answer to mother of a child that will not take
ORS 89 90
% giving three correct answers to mother of child that will not take ORS 21 19
% able to give at least one correct response on how to prevent diarrhoea 98 97
% able to give three or more correct responses on how to prevent diarrhoea 67 56
Malaria
% giving correct answer on how malaria is caught 99 97
% saying they would give Chloroquine 74 69
% saying they would refer to a health facility 77 43
% giving correct dose of Chloroquine 9 0
HIV
% giving at least one correct response on how HIV is transmitted 93 95
% giving three or more correct responses on how HIV is transmitted 77 61
61
Table H.2 The knowledge test-case based questions, percentage of correct

answers given by LHWs, nationally and in Balochistan
Measure LHWs (%)

Total Balochistan
Growth Monitoring Card
Case 1 – Normal to Moderate Malnutrition:
% giving correct weight of child 50 33
% saying that t he child is normal or moderately malnourished 86 66
% stating that the child is growing adequately 71 53
% correctly stating that referral is not necessary 74 52
Case 2 – Severely Malnourished:
% giving correct weight of child 58 30
% saying that the child is severely malnourished 37 27
% stating that the child is failing to gain weight 35 16
% correctly stating that referral is necessary 62 56
% requesting information about eating and feeding practices 84 51
% requesting information about recent illnesses 58 41
% requesting information about eating and feeding practices and
recent illnesses 54 35
Diarrhoea/Dehydration Management
Case 1 – Mild to Moderate Dehydration:
% stating that the child is mild to moderately dehydrated 73 68
% stating that the child should be rehydrated (ORS or SSS) 82 93
% stating that the child should be breast fed more often 81 65
% stating that the child should be rehydrated (ORS or SSS) or breast
fed more often 96 97
% stating that the child should be brought back soon for reassessment 1 7
% stating that the parents should seek help soon if the child does not
improve 9 2
% correctly stating that referral is not necessary 31 27
Case 2 – Severe Dehydration:
% stating that the child is severely dehydrated 64 27
fed more often 87 93
fed more often and referred to a health centre 80 89
% stating that the child should be referred to a health centre 93 96
Respiratory Infections
Case 1 – Severe Pneumonia:
% identifying severe/very severe pneumonia 63 49
% stating that the child should be referred to a health centre 92 70
% stating that the child should be given antibiotics 87 78
62
Annexes
Measure LHWs (%)

Total Balochistan
% stating that the child should be given a single dose of antibiotics and
referred 76 60
Case 2 – Pneumonia:
% identifying pneumonia 20 32
% stating that they would give antibiotics 88 78
% stating that the child should be given fluids or breast fed more often 58 45
% stating that the child should be watched for danger signs 8 8
% stating that they would give a full course of Cotrimoxazole (of all
LHWs/supervisors) 67 54
% stating correct dose & duration of Cotrimoxazole course (of those
who would give a full course) 24 7
Pregnancy
Case 1 – Anaemia:
% identifying anaemia 97 86
% stating that they would examine the patient’s conjunctiva/eye for
anaemia 92 80
% stating that they would examine the patient’s conjunctiva/eye for
anaemia, ask about the patient’s diet and ask about recent illnesses 24 22
% stating that they would give iron tablets (Fefan) 87 75
% stating that they would advise the patient to eat iron-containing
foods 80 58
% stating that they would advise the patient to avoid heavy work and to
rest 19 28
Case 2 – Pre-eclampsia:
% stating that they would refer to a health centre and that the referral
would be urgent 73 55
63
Annexes
Annex I Training of Lady Health Workers and Lady

Health supervisors
Lady Health Workers’ training requirements

The minimum standards that are expected of the training system for LHWs are:
• Three months full time basic training for each LHW at the health facility where she
was recruited.
• Twelve months task based (in-service) training, comprising one week full-time per
month for twelve months at the health facility.
After 2005, the LHWP has introduced 15 days mandatory refresher trainings for all the Lady
Health Workers. The lady health workers are provided with 15 days compulsory refresher
training on different topics, which are decided by the National training cell in consultation with
the provinces
All the LHWs who were recruited before 2005 were provided with a refresher training on the
revised LHW manual.
In addition, training can be provided, though not on a universal and compulsory basis, via:
• Training given in monthly health facility meetings; It is for one day.

• Training by supervisor in one-to-one monthly supervisory meetings.
Lady Health Supervisors' training requirements
The minimum standards that are expected of the training system for LHW supervisors are as
follows:
• Phase One: Three months training including initial training using the same curriculum
as the LHW (8 weeks) and on supervisory skill (3 weeks);
• Phase Two: Three months task-based training with two weeks in the field and two
weeks at their training centre; and
• Phase Three: Six months task-based training with three weeks in the field and one
week at their training centre.
The training pattern was changed in 2005 and the new training schedule is as follows:
• Phase One: Three months training including the initial training, using the same
curriculum as the LHW (8 weeks) and additional supervisory skills (3 weeks);
• Phase Two: Nine months of task based training with three weeks in the field and one
week at their training centre.
In addition, training can be provided, though not on a universal and compulsory basis, via:
• Training given in monthly DPIU meetings; and

• Training by supervisor (FPO, ADC, etc) in one-to-one monthly supervisory meetings.
65
Table I.1 Training Received by Lady Health Workers
Category Nation Punjab Sind NWFP Baloch AJK

al & ICT h istan &FA
averag NA
e
% of LHWs with initial training 100 100 100 100 100 100
Duration of initial training (% of LHWs)
Less than three months 0 0 0 0 0 0
Three months 94 93 93 96 100 96
More than three months 6 7 7 4 0 4
Total 100 100 100 100 100 100
Mean months for initial training 3.1 3.1 3.1 3.1 3.00 3.2
Proportion of LHWs attended part-time
training (one week/month) 96 96 98 98 76 95
Mean months of part-time training
attended 11.6 11.7 11.4 11.8 11.6 11.8
Training was imparted by:* (% of
LHWs)
Medical doctor (male) 88 91 87 74 97 93
Medical Doctor (female) 18 4 28 10 77 17
Lady Health Visitor 25 34 23 2 24 33
Dispenser 67 89 32 80 40 78
Male medical health technician 17 14 3 58 32 16
Female medical health technician 5 3 11 13 7 0
Others 5 4 6 3 3 12
Proportion of LHWs who received
task-based training (one week/month) 96 96 98 98 76 95
Mean months of task-based training 11.6 11.7 11.4 11.8 11.6 11.8
Proportion of LHWs who received
refresher training 97 95 10 98 98 95
Source: Quantitative Survey Report 2008. Note: * Multiple responses expected.
66
Annexes
Annex J Supervision
Table J.1 Supervision of Lady Health Workers
Category National Punjab Sindh NWFP Balochistan AJK &

average & ICT FANA
% LHWs without supervisors 3 2 0 3 9 8
% LHWs who have had a monthly
meeting at the health facility within:
Last 30 days 91 99 83 93 65 89
31-60 days 67 0 15 6 23 11
More than 60 days 12 1 3 1 8 0
Never attended 0 0 0 0 5 0
Total 100 100 100 100 100 100
67
Annexes
Annex K Work planning and reporting
Work planning is an important self-management tool for LHWs. The LHW reports contribute
to the Programme’s management information system. For Balochistan LHWs 47% could
produce last month’s report were able to show their current work plan.
Table K.1 Lady Health Worker work planning and reporting
National Punjab Sindh NWFP Balochistan AJK&

Category
average & ICT FANA
LHWs who said they had
developed a work plan for
current month 86 95 72 89 58 88
LHWs who could show the
interviewer the work plan 84 95 66 89 47 84
LHWs who said they had
produced a report for previous
month 98 98 97 100 94 98
LHWs who could show the
interviewer the report 89 95 78 97 67 95
69
Annexes
Annex L Supplies of medicines and equipment
Table L.1 Lady Health Worker stock of medicines, nationwide
% LHWs-out %of LHWs – If they had

of stock at with item out of stock:% LHW
Item Stock units
time of stock for more with expired
survey than 3 months stock
Paracetamol tablets (500mg) Strip pack 32 46 0.6
Paracetamol syrup Bottle 45 9. 0.7
Chloroquine tablets (250mg) Strip pack 56 14 1.8
Chloroquine syrup Bottle 58 13 0.3
Mebendazole tablets (100mg) Strip pack 62 20 0.5
Piperazine syrup Bottle 50 10 0.1
Oral rehydration salts Packet 41 4 0.9
Eye ointment Tube 59 10 0.0
Cotrimoxazole syrup Bottle 69 14 0.5
Vitamin B complex syrup Bottle 40 3 0.0
Iron and folic acid tablets (Fefan) Strip pack 34 10 0.0
Antiseptic lotion Bottle 60 10 1.8
Benzyl benzoate Bottle 53 6 2.5
Bandages (cotton) Pack 42 7 0.0
Condoms Piece 34 3 0.0
Oral contraceptive pills Cycle 22 1 0.0
Injection contraceptives 76 16 0.0
Source: Quantitative Survey Report 2008. Note: Number of LHWs with oral rehydration salts in stock was too
small to provide reliable estimates.
Table L.2 Percentage of Lady Health Workers with functional equipment and
administrative materials
Percentage of LHWs who have Item

Item Nationally Punjab Sindh NWFP Balochistan AJK&
& ICT FANA
Weighing scale 32 39 23 30 11 34
Thermometer 59 72 43 47 24 81
Torch 36 41 32 33 23 47
Scissors 73 86 54 73 41 78
Household register 97 97 98 100 84 98
Diary:
New Format 78 78 71 89 51 94
71
Percentage of LHWs who have Item

Item Nationally Punjab Sindh NWFP Balochistan AJK&
& ICT FANA
Old Format 59 47 87 64 57 44
Manual:
Current LHW manual 85 87 82 93 65 88
Refresher LHW manual 83 88 73 95 57 82
LHW manual – old version 65 56 84 69 60 64
Counselling card manual 85 81 93 55 81 83
(Refresher)
Child health refresher 93 86 92 52 76 88
manual
Injectable contraceptive 88 75 90 42 81 82
refresher manual
Revised MIS refresher 63 60 87 34 82 65
manual
OBSI refresher manual 83 79 94 37 85 80
Blank growth monitoring
cards 72 76 62 88 42 69
ARI case management
charts (all 3) 90 96 82 96 54 90
Diarrhoea case
management chart 90 95 83 97 61 90
Plastic cards 72 79 55 92 48 57
Family planning charts 90 96 81 96 63 88
Eye chart 78 80 68 92 61 74
Maternal health chart 89 94 81 99 62 91
Health house board 84 84 78 92 86 76
Blank referral slips 76 80 57 97 69 67
72

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Lady Health Worker Programme

External Evaluation of the

Oxford Policy Management

Cover photo: Village girl in rural Punjab

• Dr Franklin White (Pacific Health and Development Sciences)

In addition to providing preventive and promotive services, curative services continue to be

Differing levels of performance

• Retain experienced LHWs;

The knowledge test

• Retain experienced LHWs;

Organisational support – supervision, pay and supplies

7.3 Improving distribution and supply ......................................................................... 36

ADC Assistant District Coordinator

1 Evaluating the Lady Health Worker Programme

• Providing accessible promotive, preventive, curative and rehabilitative services to the

1.2 Lady Health Worker Programme evaluation

Specifically, this report covers the following areas:

In addition to problems of sample comparability caused by insecurity, there was an additional

1.3 Characteristics of Lady Health Workers

Figure 1.1 Percentage of LHWs who have replaced an LHW in their

Source: Quantitative Survey Report 2008.

Figure 1.2 Percentage of LHWs serving their original catchment area

Source: Quantitative Survey Report 2008.

LHWs and Mobile Phones

Source: Quantitative Survey Report 2008.

1.4 Key points

2 Providing services at the doorstep

2.1 Levels of service delivery

• Hygiene education on drinking water and sanitation;

Figure 2.1 Lady Health Workers average coverage of preventive and

Source: Quantitative Survey Report 2000 and 2008

2.2 Delivery of curative services

Measure Punjab Sindh NWFP Balochistan AJK &

2.3 Activities in the community

Figure 2.2 Activity and meetings of women’s health committees, by province

Source: Quantitative Survey Report 2008.

2.4 Referral to health facilities

Figure 2.3 Place of referral of last acute case by LHW in Balochistan

Source: Quantitative Survey Report 2008.

Table 2.2 Comparison on LHW reports on referrals to health facilities

Punjab Sindh NWFP Balochistan AJK/FANA Overall

2.5 Contribution to National Immunisation Days (NIDS)

Figure 2.4 Participation of LHWs in NIDS in the past three months

Source: Quantitative Survey Report 2008.

2.6 Key points

3.1 Performance of Lady Health Workers in service delivery

Figure 3.1 Comparing Lady Health Worker provision of service by

Source: Quantitative Survey Report 2000 and 2008.

Figure 3.2 Proportion of Balochistan Lady Health Workers in each

Source: Quantitative Survey Report 2000 and 2008

3.2 Explaining high performance

• Retain experienced LHWs;

3.3 Key points

4 The Lady Health Worker workload

4.1 Client registration

Figure 4.1 Average number of persons registered with the LHWs

2000/01 1062 898 952 723 855

Source: Quantitative Survey Report 2000 and 2008.

4.2 Time spent working