Khailtul Faiz, 48, started her career as a Lady Health Worker (LHW) in Jamal Dheri village of Matiari district in Sindh province in 1995. She was among the first batch of LHWs in Sindh. She vividly remembers the year she started her work; that year 12 children and three mothers died in her village which had a population of less than 2,000. Of the 12, nine children died of measles and three of birth-related complications.

"In 1996, for the first time, I vaccinated children against measles and since that year not even a single child has died in our village because of this disease and only one mother died while giving birth to a child," she tells TNS.

There was a lot of resistance from the society against her joining the profession. Her family suffered a lot. The population of the village kept increasing while she was the only LHW to tackle it. "Finally in 2007, when the population reached over 2500 in the village, they deputed another LHW," she says.

She complains how the LHWs have not received the support of both the society and the governments. People make fun of them and they don’t have job security either. "We never get our remunerations in time," says Faiz.

She was among the first 10 women who set up a union of LHWs in Sindh and started struggle to get their services regularised. They started this struggle in 2010 and got regularised in Sindh only last month, in September 2014. During this time, they faced state oppression. "Over 300 of our co-workers were arrested and cases registered against them under anti-terrorism laws. Husbands and sons of our colleagues were booked under anti-terrorism laws. At least three of our co-workers were divorced during our struggle as their husbands wanted them to leave the struggle under pressure from different quarters," she says.

In 1995 Faiz used to receive Rs1000 as monthly remuneration which only increased to Rs7000 in 2014.

In 2012, the Supreme Court of Pakistan ordered the government to regularise LHWs in the country but "even then it took two years of struggle to get our right". She says that an LHW performs more than 20 tasks, though the main objective of the programme was family planning.

In September 2014, the four provincial governments regularised the services of over 90,000 LHWs and other staff, 20 years after the programme was launched under the late premier Benazir Bhutto’s government. The programme has, so far, trained over 100,000 women to provide community health services mainly in the rural areas.

The LHW programme has led to the development of a very well-placed cadre that links first level care facilities to the community, thus improving the delivery of primary healthcare services. The programme has not only revitalised the primary healthcare system in the country but has also helped overcome the gendered division of public and private space that is a major obstacle to women’s access to basic services, including education, and employment opportunities.

The programme is now a major employer of women in the non-agricultural formal sector in rural areas. "These are agents of change in our society," says Nasir Mansoor, a Karachi-based senior leader of National Trade Union Federation. "They even serve in the areas where police fears to go in Karachi. These are very courageous women. Despite the fact that seven of them have been killed in Karachi, they have not left doing their job of vaccinating people in the poor and backward areas." He says that it is their right to get job security. "They have fought courageously to get their right. This is not a privilege as being portrayed by provincial governments which have regularised them. This step is a token recognition of their services."

Each LHW serves a population of 1,000 people in the community and extends her services in the catchment population through monthly home visits. The scope of work includes over about 20 tasks, covering all aspects of maternal health, newborn and childcare. LHWs’ main job is to support maternal and child health services, which include family planning, HIV/AIDS and treatment of minor illnesses. The services they provide include: health education and promotion of healthy behaviour, including the use of basic preventive health services; family planning services, including contraceptives; and basic curative care and with training to identify and refer more serious cases.

They also register the population of their service area, focusing on the priority age groups such as children under five and eligible couples for family planning. They act as a liaison between the formal health system and the community and disseminate health education messages on hygiene and sanitation. Almost 60 per cent of the total population of Pakistan, mostly rural, is covered by the programme with more than 90,000 LHWs all over the country.

A third-party evaluation conducted in 2000-01 by Oxford Policy Management (OPM) found that the population served by LHWs has substantially better health indicators than other areas. In 2006, a study in Punjab province showed LHWs contributed to reduction in maternal mortality rate from 350 to 250 per 100,000 live births and infant mortality rate from 250 to 79 per 100,000 live births.

A research study in 2011 done by researchers from Aga Khan University in Karachi who followed almost 50,000 households in two district of Sindh province found that the areas where LHWs were assigned to work had 21 per cent fewer stillbirths and 15 per cent fewer newborn deaths than in other areas.

However, despite its success and the trust it has earned from the community, there are certain areas which need special attention; these include poor support from sub-optimal functional health facilities, financial constraints and political interference leading to management issues. "That success was achieved even though the health workers generally had only 10th-grade educations and one extra week of training for the project. Also, they failed to hold almost half the planned group sessions for pregnant women and visited only a quarter of the babies within a day of birth," reads the study.

In 2011, Dr Donald Thea, a Boston University researcher who worked on LHWs Programme in Pakistan, termed it one of the best community-based health systems in the world while talking to the New York Times. The programme has achieved a lot in terms of family planning, immunisation campaigns and contraceptive prevalence rate (CPR). OPM evaluation in 2000 found that the programme had helped increase CPR in LHW covered areas from 11 per cent in 1994 to 33 per cent, which was considerably higher than the national average of 22 per cent.

A USAID policy brief in 2012 showed that LHWs used to allocate 12.8 per cent of their time to family planning while in 2008 this decreased to 9 per cent. The brief found that an LHW serves around 2.4 household and 1.9 patients per week. The brief also found it a relatively expensive programme.

"In the 2003-8 period, the LHW Programme was allocated a budget of Rs5.3 billion per year. Based on the 9 per cent time that LHWs spend on family planning, the LHW programme spent Rs478 million on FP annually, with the average cost of FP services per woman served per year of Rs1392 (USD 23). These are high compared to regional or some national NGO costs of USD 3-6."

Khailtul Faiz admits the quality of the programme went down after 2000. "There are issues with trainings. Majority of the newly recruited workers do not know how to perform most tasks as they have not gone through extensive training. LHWs also used to be provided with life-saving medicines by 2000 but they stopped providing us those medicines after that year," she says.

Sajida Hameed, a senior leader of LHWs in Punjab, says that after regularisation an LHW’s salary stands at Rs14,000. "An LHW is supposed to serve a population of 1000 or 150 households but majority of them serve over 200 households and a population of over 1300." She says the focus of LHWs has shifted from family planning to other tasks. "Majority of them could not perform their routine tasks because of anti-polio vaccination programme. This has also hurt our performance in the last decade or so."

She says that under-funding is a problem and coverage also needs to be increased and "this can only be done by hiring more LHWs and providing them better training".

Authorities do admit there are issues of under-funding and training which have been hampering the quality of LHW’s programme. "There are some bottlenecks and we have been trying to address them," says Dr Zahid Pervaiz, director general health Punjab province who also oversees LHWs programme in the province.

"There are some problems with funding, training and logistics. We have been changing the TORs and integrating different programmes with same tasks." He says that health sector is a multi-tasking sector. "They need to be prepared to perform different tasks. I admit that we have not been able to provide them quality training during the last few years. There were some problems of ownership with the programme after the 18th Amendment but now that the provinces have taken the ownership of these programmes, hopefully issues like funding would be solved."