cross-sectional survey taken in five rural villages of Sindh, with 669 women who gave birth between July 2010 and September 2014, showead that women residing in these areas have limited access to outreach health facilities in the region due to difficult terrain, inadequate transportation and financial constraints.

To improve maternity-care access for rural women, the government has set up a large network to provide reproductive and maternity-care services.

Primary healthcare providers (midwives, doctors) and community health workers (lady health worker and community midwife) appear to provide a good structure to deliver healthcare services for women living in rural and remote regions. Primary healthcare centres located in remote regions provide subsidised pregnancy and delivery care and refer high risk and complicated pregnancies to tertiary care hospitals. Lady health workers (LHW) are trained to offer individual level counselling, health education, safe pregnancy and childbirth practices, breast feeding and infant care, appropriate vaccination for both mother and child at health centres and their homes.

The lady health workers programme was launched in 1994 to increase access to basic preventive healthcare services, particularly in rural areas. Lady health workers deliver a range of services related to maternal and child health problems. They treat minor ailments and injuries and are trained to identify and refer more serious cases to secondary and tertiary care.

Family planning aims women to understand the importance of contraception for better mother’s health and care of under-five children at home. This includes providing contraceptive pills and condoms, and referring consenting clients for intrauterine device provision and/ or sterilisation. Basic health units, rural health centres, district hospitals and family welfare centres are established to provide contraception and family planning. As part of their role, community health workers counsel women to attend these clinics.

Lady health workers are also engaged in the implementation of many public health programmes including those on tuberculosis treatment, malaria control, immunisation, polio eradication and health education. The WHO supports the Pakistani health authorities in training lady health workers, revising their curriculum and other related human resource capacity building. The WHO also provides opportunities of updating knowledge and skills through regular refresher courses and assists in creating a feasible health management information system for the programme.

The community midwives play an important role in providing easy access to healthcare. They provide birthing care services for women who prefer homebirths, or who live far from facilities, either in the woman’s home or in their community-based clinic.

In low-middle income countries worldwide, micro-health insurance (MHI) schemes have emerged as a tool for financing health budget. Health insurance schemes can be introduced against collection of micro-payments to facilitate low-income households.

Community health worker teams at the container-based health centres provide counselling and health awareness to local communities. They also provide midwifery services.

Sehat Sahulat Programme is a milestone towards ensuring that identified under-privileged citizens across the country get access to their entitled medical treatment without any financial obligations. It is managed by the Punjab Health Initiative Management Company (PHIMC) in the Punjab. This programme functions as a micro health insurance scheme. It offers Rs 600,000 per family/ year coverage for priority in-patient treatment for serious illnesses like cancer, dialysis, cardiac surgery, prosthetic implants, chronic liver diseases etc.

Non-governmental organisations are working to establish structured primary healthcare institutes in rural areas. Trained doctors are replacing unqualified practitioners/ quacks to provide optimum healthcare services. The Health and Nutrition Development Society (HANDS), Indus Health Network, Sina Health, Education and Welfare Trust have laid down infrastructure to make access to health facility possible. The Indus Health Network is providing primary healthcare across 31 facilities in urban and rural areas across 14 districts.

Container-based community health centres are an innovation to healthcare problems of our country. Container clinics not only provide consultation to patients but also provide medicines free of cost and offer laboratory tests free of charge. Community health worker teams at the container provide counselling and health awareness to local communities. They also provide midwifery services to benefit women. The Indus Hospital launched the first boat clinic in Pakistan to provide healthcare access to maritime communities cut off from healthcare access. The boat clinic is operating in Jampur in southern Punjab. These primary care set ups provide free of cost consultation and have diagnostic services too. There are also medical buses active in Badin and Tharparkar that have impacted a large pool of population. This reduces the door-to-diagnostic evaluation time of patients by making healthcare available in their vicinity.

Provision of optimum health to community not only depends on available centres and doctors; a large part is contributed by educationalists and infrastructure that ensure the availability of food and water.

The Khubaib Foundation believes in working at the roots. Water scarcity is the main issue in many rural areas. Over eighty percent of the people in Tharparkar are dependent on rain-fed agriculture for their livelihoods as well as on livestock. Water shortage is a major problem in the area. In Thar, dug-wells have been found to be the only sustainable source of water.

Malnutrition is a major cause of deaths among people there including children, water borne diseases and lack of water are a common occurrence. The Khubaib foundation has built dozens of water wells across Pakistan. They are working to reframe the infrastructure to ensure basic life provision.

Telehealth has proved to change the face of healthcare system as witnessed during the Covid-19 pandemic. Many organisations have established stations in remote areas to cater the population there. Sehat Kahani is one such example. These aim to ensure affordable specialised care from examination to treatment by connecting doctors online to patients at e-clinics as people in remote areas are usually unable to directly contact doctors online. The network exists in all four provinces and in Azad Jammu and Kashmir. It has a total of 49 e-health clinics. To date, Sehat Kahani has provided consultation to more than 500,000 women. By the end of 2023, they aim to increase the number of e-clinics to 150. They are also providing disease awareness and health education.

The existing primary health structure in Pakistan provides a good foundation to deliver continuity of care services. However, health services utilisation for reproductive and maternity care remains suboptimal for women who live in geographically remote regions.

With the initiative already taken, we aim to take it ahead through improvement of infrastructure, training of healthcare personnel and adequate transport.

The writer, MBBS, FCPS, MRCGP (INT), is a family medicine consultant at the Raazi Alkhidmat Hospital, Islamabad