Lady Health Workers Program (LHWP): In Pakistan, female health workers (known locally as a 'lady health workers') have

formed the backbone of the primary health care system for the past fifteen years. Using women in this role is very helpful in a country such as Pakistan, where direct interaction between women and men is not encouraged. Pakistan is committed to the goal of making its population healthier, as evidenced by the continuing strong support for the Social Action Program (SAP) and by the new vision for health, nutrition, and population outlined in the National Health Policy Guidelines published by the government. Lady health workers: A recent initiative, lady health worker, has turned out to be a promising community-based health worker program. These workers bring health information, some basic health care and family planning services to doorsteps of women. These women are members of the communities they serve and are responsible for 150200 households (around 1,000 people) each. They provide primary health care with a focus on reproductive health and family planning. During the day, lady health workers visit women at their homes; in the evenings, community members who need help go to their local lady health workers home (known as the health house) for health advice and basic care, including first aid. Launched in 1994 by former Prime Minister Benazir Bhutto's government, Pakistans Lady Health Workers program has trained over 100,000 women to provide community health services in rural areas. The program website introduces it as follows: "This country wide initiative with community participation constitutes the main thrust of the extension of outreach health services to the rural population and urban slum communities through deployment of over 100,000 Lady Health Workers (LHWs) and covers more than 65% of the target population. The National Programme for Family Planning and Primary Health Care is funded by the Government of Pakistan. International partners offer support in selected domains in the form of technical assistance, trainings or emergency relief." The program is now a major employer of women in the non-agricultural formal sector in rural areas, and is being more than doubled in size if budget allocations can be sustained. If universal coverage is achieved, every community in the country will have at least one lady health worker, one working woman and potential leader, who could serve as a catalyst for positive change for women in her community. The health officials say that unlike the mid-1990s when it was difficult to recruit women because of the minimum 8th grade education requirement, now there are large numbers of women who meet the requirement lining up for interviews in spite of low stipend of just Rs.7000 per month. Private sector is also helping the LHW program. Mobile communications service provider Mobilink has recently partnered up with the United Nations Population Fund (UNFPA), Pakistan's Ministry of Health and GSMA Development Fund in an innovative pilot project which offers low cost mobile handsets and shared access to voice (PCOs) to LHWs in remote parts of the country. Mobilink hopes to bridge the communication gap between the LHW and their ability

to access emergency health care and to help the worker earn extra income through the Mobilink PCO (Public Call Office). Health Concerns of LHW: Priority diseases: Most common and dangerous diseases in Pakistan include:

Acute respiratory infection (51%): Among the victims of ARI, most vulnerable are children whose immune systems have been weakened by malnutrition. In 1990, National ARI Control Programme was started in order to reduce the mortality concerned with pneumonia and other respiratory diseases. In following three years, death rates among victims under age of five in Islamabad had been reduced to half. In 2006, there were 16,056,000 reported cases of ARI, out of which 25.6% were children under age of five. Viral hepatitis (7.5%): Viral Hepatitis, particularly that caused by types B and C are major epidemics in Pakistan with nearly 12 million individuals infected with either of the virus. The main cause remains massive overuse of therapeutic injections and reuse of syringes during these injections in the private sector healthcare. Malaria (16%): It is a problem faced by the lower-class people in Pakistan. The unsanitary conditions and stagnant water bodies in the rural areas and city slums provide excellent breeding grounds for mosquitoes. Use of nets and mosquito repellents is becoming more common. A Programme initiated by the government aims to bring down malarial incidence below 0.01% by the year 2011. In Pakistan, malarial incidence reaches its peak in September. In 2006, there were around 4,390,000 new reported cases of fever. Diarrhea (15%): There were around 4,500,000 reported cases in 2006, 14% of which were children under the age of five. Dysentery (8%) and Scabies (7%) Others: goiter, hepatitis and tuberculosis

Controllable diseases Cholera: As of 2006, there were a total of 4,610 cases of suspected cholera. However, the floods of 2010 suggested that cholera transmission may be more prevalent than previously understood. Furthermore, research from the Aga Khan University suggests that cholera may account for a quarter of all childhood diarrhea in some parts of rural Sindh. Dengue fever: An outbreak of dengue fever occurred in October 2006 in Pakistan. Several deaths occurred due to misdiagnosis, late treatment and lack of awareness in the local population. But overall, steps were taken to kill vectors for the fever and the disease was controlled later, with minimal casualties. Measles: As of 2008, there were a total of 441 reported cases of measles in Pakistan. Meningococcal meningitis: As of 2006, there were a total of 724 suspected cases of Meningococcal meningitis. Poliomyelitis: Pakistan is one of the few countries in which poliomyelitis have not been eradicated. As of 2008, there were a total of 89 reported cases of polio in Pakistan. Polio cases

may be on an increase. The year 2010 saw an increase in the number of cases as well identification of polio from new locations. Experts from the national program and the WHO felt that the new cases identified from southern Punjab and northern Sindh may have resulted from importation of infections from other locations in Pakistan. Locations in FATA and Khyber Pakhtunkhwa remain hosts for year round persistence of infection and environmental sampling by the national program and WHO suggests that polio remains endemic in many other parts of the country. HIV/AIDS: The AIDS epidemic is well established and may even be expanding Pakistan. Risk factors are high rates of commercial sex and non-marital sex, high levels of therapeutic injections (often with non-sterile equipment), and low use of condoms. The former National AIDS Control Programme (it was devolved with the Health Ministry) and the UNAIDS state that there are an estimated 97,000 HIV positive individuals in Pakistan. However, these figures are based on dated opinions and inaccurate assumptions; and are inconsistent with available national surveillance data which suggest that the overall number may closer to 40,000. Family planning: The government of Pakistan wants to stabilize the population (achieve zero growth rate) by 2020. And maximizing the usage of family planning methods is one of the pillars of the population program. The latest Pakistan Demographic and Health Survey (PDHS) conducted by Macro International with partnership of National Institute of Population Studies (NIPS) registered family planning usage in Pakistan to be 30 percent. While this shows an overall increase from 12 percent in 1990-91 (PDHS 1990-91), 8% of these are users of traditional methods. Approximately 7 million women use any form of family planning and the number of urban family planning users have remained nearly static between 1990 and 2007. Since a many of contraception users are sterilized (38%), the actual number of women accessing any family planning services in a given year are closer to 3 million with over half buying either condoms or pills from stores directly. Government programs by either the Health or Population ministries together combine to reach less than 1 million users annually. Thus, fertility remains high, at 4.1 births per woman. Owing to such high fertility levels, Pakistan's overall population growth rate is much higher than elsewhere in South Asia (1.9 percent per year). Some of the main factors that account for this lack of progress with Family Planning include inadequate programs that don't meet the needs of women who desire family planning or counsel users of family planning about potential side effects, a lack of effective campaign to convince women and their families about the value of smaller families and the overall social mores of a society where women seldom control decisions about their own fertility or families. However the single most important factor that has confounded efforts to promote family planning in Pakistan is the lack of consistent supply of commodities and services. Indeed, the unmet need for contraception has remained high at around 25% of all married women of reproductive age (higher than the proportion that are using a modern contraceptive and twice as high as the number of women being served with family planning services in any given year) and historically any attempt to supply commodities has been met with extremely rapid rise (over 10% per annum) in contraception users compared with the 0.5% increase in national CPR over the past 50 years.

Currently the government contributes about a third of all FP services and the private sector including NGOs the rest. Within the private sector, franchised clinics offer higher quality health care than un-franchised clinics but there is no discernible difference between costs per client and proportion of poorest clients across franchised and un-franchised private clinics. Government programs are run by both the Ministries of Population Welfare and Health. The most common method used is female sterilization which accounts for over a third of all modern method users. Unfortunately this happens too late for most women as sterilized women are over 30 years of age and have 4 or more children. Condoms are the next most popular method. Maternal and child health: In June 2011, the United Nations Population Fund released a report on The State of the World's Midwifery. It contained new data on the midwifery workforce and policies relating to newborn and maternal mortality for 58 countries. The 2010 maternal mortality rate per 100,000 births for Pakistan is 260. This is compared with 376.5 in 2008 and 541.2 in 1990. The less than 5 mortality rate, per 1,000 births is 89 and the neonatal mortality as a percentage of under 5's mortality is 48. The aim of this report is to highlight ways in which the Millennium Development Goals can be achieved, particularly Goal 4 Reduce child mortality and Goal 5 improve maternal death. In Pakistan the number of midwives per 1,000 live births is 10 and 1 in 93 shows us the lifetime risk of death for pregnant women. There is a huge imbalance in these figures. In Baluchistan, for instance, the maternal mortality is 785 deaths per 100,000 live births which are nearly triple the national rate. It should be noted here that in rural Pakistan, maternal mortality is nearly twice than that in cities. The sad reality is that 80 per cent of maternal deaths are preventable. Conclusion: Due to economic downturn and security challenges in several conflict areas since 2008, Pakistan's chances of achieving its Millennium Development Goals (MDGs) by 2015 appear to be slim. However, significant timely expansion in the LHW program and making it more effective can still help Pakistan get close to its MDGs on important health indicators like the infant mortality rate (IMR) and the maternal mortality rate (MMR).