Wazir et al.

Reproductive Health 2013, 10:60

http://www.reproductive-health-journal.com/content/10/1/60

REVIEW Open Access

National program for family planning and primary

health care Pakistan: a SWOT analysis
Mohammad Salim Wazir1, Babar Tasneem Shaikh2* and Ashfaq Ahmed1

Abstract
Background: The National Program for Family Planning and Primary Healthcare was launched in 1994. It is one of
the largest community based programs in the world, providing primary healthcare services to about 80 million
people, most of which is rural poor. The program has been instrumental in improving health related indicators of
maternal and child health in the last two decades.
Methods: SWOT analysis was used by making recourse to the structure and dynamics of the program as well as
searching the literature.
SWOT analysis: Strengths of the program include: comprehensive design of planning, implementation and
supervision mechanisms aided by an MIS, selection and recruitments processes and evidence created through
improving health impact indicators. Weaknesses identified are slow progress, poor integration of the program with
health services at local levels including MIS, and de-motivational factors such as job insecurity and non-payment of
salaries in time. Opportunities include further widening the coverage of services, its potential contribution to health
system research, and its use in areas other than health like women empowerment and poverty alleviation. Threats
the program may face are: political interference, lack of funds, social threats and implications for professional
malpractices.
Conclusion: Strengthening of the program will necessitate a strong political commitment, sustained funding and a
just remuneration to this bare foot doctor of Pakistan, the Lady Health Worker.
Keywords: SWOT, Primary healthcare, Human resources for health, Management information system, Lady health
worker, Vertical program, Developing countries, Pakistan

Background providing primary health care services to more than 80

Role of community health workers in primary health million people of the country at their door steps [3,4].
care provision has now been well established and oft- The main thrust of the program is to extend the out-
documented for improving the health of the population, reach services to the communities through selection and
particularly in countries which face serious dearth of training of 100,000 Lady Health Workers (LHWs) from
skilled human resource [1]. Commonly known as “Lady all over the country, in a phase-wise manner. The pro-
Health Workers’ Programme”, National Program for gram was designed as an integral part of existing health
Family Planning and Primary Health Care was launched care delivery system of the country through locally iden-
in April 1994 by the then Prime Minister of Pakistan, tified literate female workers who were trained on
Mohtarama Benazir Bhutto, as a major initiative to pro- primary health care and placed in the communities to
vide universal health coverage to the people of Pakistan which they belonged. The LHWs are trained to provide
fulfilling the Program of Action brought from ICPD held essential maternal and child health care including family
in Cairo [2]. Her motivation led to one of the largest planning, management of minor and common ailments
and successful community based programs in the world and imparting health education [5].
Since the Alma Ata declaration in 1978, global efforts
* Correspondence: [email protected] to improve access to primary health care for poor and
2
Department of Health Systems & Policy, Health Services Academy,
Islamabad, Pakistan vulnerable populations had started [6]. Latin America,
Full list of author information is available at the end of the article

© 2013 Wazir et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication
waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise
stated.
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Tanzania, Mozambique, and China were the leading via Google Scholar and PubMed. MeSH words used
countries where large scale community based health were Primary Healthcare, Human Resources for Health,
programs were initiated. The concept of “barefoot Management Information System, Lady health worker,
doctors” during 1960s in China has a history of provid- Vertical program, Developing countries, Pakistan. All
ing basic health care to rural populations. Deployment those research papers were excluded which used LHWs
of community health workers (CHWs) has been a recog- as data collectors or studied their services rendered in
nized strategy to provide basic health care at community the communities. Papers which were developed around
level and to bridge the gap between community and the the programme per se were included. This analysis
health system in low and middle income countries [3]. helped in making recourse to program structure, dynamics
During 1970s and 80s, health indicators related to mater- and reports documented so far.
nal and child health were poor in Pakistan. Major reasons
were: communication gap between community and na- Review
tional health system, resource crunch, and spending the
available resources on tertiary care and neglecting primary a) STRENGTHS: Panel 1 gives an account of the
health care and rural population. Being signatory to Alma strengths.
Ata declaration, the Government of Pakistan took concrete
steps in collaboration with World Health Organization Panel 1: STRENGTHS
(WHO), and launched its first nation-wide community
based health programme known as Lady Health Worker’s  Political commitment
Program in 1994 [7]. LHWs are recruited through a strict  Recruitment and Selection procedures
recruitment and selection criteria laid down in the basic  Wide coverage outreach – rural areas focused
design of the program. After her recruitment, each LHW  Integrations with healthcare system at upper levels
has to undergo 15 months training after which she is sup-  Defined management and supervisory structures
posed to serve a population of about 1000 or 150 homes  Comprehensive healthcare provision
by visiting 5-7 homes on daily basis [7,8]. Currently over  Management Information System (MIS)
100,000 LHWs are working in the country covering about  Training of LHWs part of the system
60-70% of the population which is mostly rural. The  Positive impact on health indicators
government is spending on average PKRs 44,000 per  Cost effective intervention
LHW, on annual basis [7,9].
The Program is directly contributing to the Millennium
Political commitment
Development Goals (MDGs) 1, 4, 5, and 6; and indirectly
It is heartening to see that the LHW programme
to MDG 7. After the devolution of health system in
received adequate political commitment, no matter
Pakistan in 2011, and when the provinces are strategizing
which regimen was in power, military or democratic
for their respective health sector programmes [10], it is
since 1994. There has been a wide recognition of the
an opportune time to do a stock-taking of the LHW
programme among the political arena and all govern-
programme. Therefore, in this paper, the National Program
ment quarters. The financial and administrative support
for Family Planning and Primary Health Care is
has continued without any interruption.
assessed using the SWOT analysis technique. SWOT
is the acronym for Strengths, Weaknesses, Opportun-
ities and Threats. This tool identifies and assesses Recruitment and selection
strengths and weaknesses of the organization. It also The main strength of this nation-wide coverage has been
identifies the opportunities and threats that exist in attributed to program strategy of rapidly recruiting, train-
the external environment that should be utilized and ing, and deploying community based female workers
avoid respectively. It is a subjective tool in which the primarily identified by the community itself [12]. The
assessor categorizes the strengths, weaknesses, oppor- process enables the communities to identify appropriate
tunities and threats as per perceptions and not by females for jobs providing sense of ownership to the com-
objective or quantifiable measures. The analysis pro- munities. This ensures empowerment of women selected
vides a basis to assess the likelihood of a program’s for the job, thus improving their social status, quality of
success or failure [11]. The analysis is presented life and overall livelihood.
under the aforementioned four headings.
Wide coverage
Methods It is one of the largest community based programs cov-
Method used for the SWOT analysis is primarily a litera- ering up to 60-70% of the population comprising mainly
ture review of about 22 peer reviewed papers, searched the rural poor through regular outreach activities.
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Integration but also helps supervisors and managers of the program

The program is loosely integrated into existing health to assess the performance of the respective LHW. More-
system at least at the higher tiers. over, it collects information at household level, thus ac-
counting for clients going to both private as well as
Management and supervisory structures government health facilities [7].
The program is comprehensively designed with imple-
mentation strategies and is also blessed with well- Training
planned management and supervisory structures ensur- Facility based and paid training of LHWs has been
ing regular and periodic monitoring and evaluation. effective and efficient with recognized curricula and
Each LHW is supervised through supportive supervision other protocols beside regular refresher courses.
by the lady health supervisors (LHS), District Coordin-
ator, Assistant District Coordinator, Provincial Field Impact of the program
Programme Officer and Executive District Officer Community health workers have made a measureable
(Health). However, the immediate and regular supervi- impact on health indicators by bridging the gap between
sion is the responsibility is of LHS. An LHS is supposed community and the health care delivery system, enhan-
to supervise 20 to 25 LHWs during the month and visits cing health service utilization and creating awareness
each LHW at least once a month in her health house about health practices among people through health
and assess her work through records and physical verifi- education [4]. Oxford Policy Management in its evalu-
cation in randomly selected households from the treat- ation report documented significant difference in health
ment register of the respective LHW. The LHW indicators in areas covered by LHWs as compared to
program demonstrates a phased scale-up with a con- non-covered areas. The demographic and health survey
scious focus on program management. It has succeeded of 2006-2007 also mentioned prominent improvement
at reaching scale and is integrated into existing public in infant mortality rate (IMR), maternal mortality ratio
health–system structures through clear policy planning. (MMR) and contraception prevalence rate (CPR) in
There is significant political will and some long-term fi- areas covered by LHWs [7,8]. The fourth comprehensive
nancial support from the federal government for this review of the program found that as compared to com-
program, which provides the potential for each layer of munities not served by the LHWs, the served house-
management to be coordinated and funded [13]. holds were 11% more likely to use modern family
planning methods, 13% were more likely to have had a
Comprehensive health care tetanus toxoid vaccination, 15% more were likely to have
LHWs program provides preventive and curative health- received a medical check-up within 24 hours of a birth,
care at the doorstep of the population. The PHC services and 15% more were likely to have immunized children
package include: treatment of minor ailments and referral below three years. The improvements in health indica-
to the first level care facilities (FLCF) when required, regis- tors among the populations covered by the LHWs were
tration of pregnant mothers for antenatal care, ensuring not attributable to the program alone. Researchers had
clean and safe delivery, counselling of pregnant and lactat- noted that other positive changes such as economic
ing mothers in related issues, screening of neonates for growth, increased provision of health services, and better
problems requiring referral, weight monitoring of the education services helped to enhance the impact [11].
children under three years of age, counselling regarding
breast feeding and weaning, counselling of eligible couples Cost effective intervention
regarding family planning, and provision of medicines and Lady health worker’s services including her salary, costs
contraceptives to patients and clients. This makes the around US$750 and whereby she covers a population of
program effective in achieving health status goals [13]. 1000 people. So services delivered by a lady health
workers are highly cost effective (around 75 cents per
Management information system person) in a poor setting and in a resource constrained
The backbone of an effective and efficient management health system [14].
of any program is its information system. LHW program
has its own comprehensive management information b) WEAKNESSES: The weaknesses of the program are
system (MIS) called LHW-MIS. The program’s MIS not identified in panel 2.
only records data about all PHC activities and logistics,
but also has a regular system of its transmission to Panel 2: WEAKNESSES
district, provincial and federal levels. The information
gathered through nine tools not only helps the LHW to  Poor management at lower level
keep track of health status of her catchment population,  Poor integration at lower levels
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 Problems in salaries payment Weak systems in supplies and equipment provision

 Job insecurity There are deficiencies in the disbursement of funds and
 Weak supplies and equipment provision supplies at all levels [11]. In spite of its large expansion,
 Weak referral systems evaluators have found that serious weaknesses in the
 Poor integration of MIS with health system provision of supplies, equipment and referral services
 Poor supervision and linkages with peripheral health need to be addressed on urgent basis [16].
facilities
 Low quality care in some parts Weak referral system
 Sinecure contingents In a comprehensive review of global community based
 Slow progress in meeting targets health programs, the Global Health Workforce Alliance
 Less impact in areas like sanitation and breast in 2010 noted that the program suffers from weak refer-
feeding ral systems, possibly due to rapid integration into a weak
national health system. Such weaknesses result from
Management and integration poor planning and lead to problems of sustainability,
Despite the phased rollout and well-planned manage- especially in both quality of care and retention of health
ment and supervisory structures, management of the workers [19].
LHW program faces several challenges. Frequent turn-
over among supervisory and logistics staff precludes the Poor integration of MIS
development of expertise among senior staff to guide the Though there is an MIS but it is not integrated with
evolution of the program and ensure quality of care [15]. overall health system [14]. This leaves a vacuum in deci-
In addition, performance monitoring reports have re- sion making because the problems and issues from the
vealed limited or uneven integration with BHUs and grass root level are not taken into consideration while
other health-related programs, depending upon the level making allocations, disbursements, procurements etc.
of functioning of the pre-existing Women’s Health Com-
mittees and BHUs. LHW program should be coherently Poor supervision and linkages with peripheral health
inserted in the wider health system [1]. In other areas, facilities
there is a significant contingent of LHWs that provide Though there are good linkages at higher levels, at the
low quality of care or do not work. This may in part be field levels i.e. BHUs and other areas, the linkages are poor
due to delays in planned improvements targeted at man- due to inherent weaknesses in the health system itself.
agement and organizational development [11,16].
Low quality care/sinecure contingents of LHWs
There are low quality services provided by LHWs in some
Salaries and jobs insecurity parts of the country. In other parts there are contingents
Recently there have been delays in paying salaries to of LHWs drawing salaries but not working making the
LHWs across the country. Widespread protests and overall performance of LHWs program weak.
demonstrations by LHWs have attracted media coverage,
which is not good for the image of the program; and Slow progress
motivation of the present and prospective workforce The progress of the program has remained slow in
[17]. Moreover, the salary is still called stipend not pro- achieving its targets.
gressive like other jobs. There is job insecurity and in
18 years since its inception the LHWs have not attained Impact
the status of government employees. Though it might be There has been less success in the areas of health knowledge,
against the spirit of barefoot doctors’ philosophy but is sanitation, and key behaviours such as exclusive breast-
needed to keep the workforce motivated. feeding for the first 6 months of life [3,13]. Less impact is also
visible in areas such as enhancing health knowledge, sanita-
Involvement in other public health interventions tion, exclusive breast feeding, and neonatal mortality.
LHWs are overworked due to their involvement in other
public health activities launched by donor agencies or c) OPPORTUNITIES: Panel 3 identifies some
NGOs or by the health department e.g. EPI, TB DOTS, opportunities for the program.
Malaria, etc [18]. Due to this overburdened job descrip-
tion and additional duties, her primary mandate i.e. Panel 3: OPPORTUNITIES
primary health care, family planning, antenatal and post-
natal care, advise on nutrition and immunization of  Wide coverage and social acceptability
mother and child etc. is at stake.  Training capacity can be used by others
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 Emergency obstetrical care training for some LHWs Poverty, patriarchy and social norms
 Health system research LHW has struggled and will be facing the daunting chal-
 Use for women empowerment lenge of prevailing poverty which is the major constraint
 Use for poverty alleviation strategies in promoting healthy behaviours among the poorest
communities they serve. Moreover, patriarchal structure
Wide coverage of society compounded with variety of social norms
The large coverage of the program and robust workforce impedes her own social mobility and jeopardizes her
can afford opportunities for future public health interven- place in the milieu [24].
tions. Given the fact that women in remote rural areas are
in need of permission to seek health care from female pro- Political interference
viders only, LHWs can be instrumental in transforming Due to huge opportunities of employment, the program
the health care seeking practices and behaviours [20]. is vulnerable to political interference.

Training in emergency obstetrics care Funds

Some LHWs based on their performances could be After the 2011 devolution, the financing mechanism of
trained and certified in providing obstetrical care of the programme has still to be decided at the provincial
basic type. Community health workers have been used level. Till then, lack of financial support by the govern-
in many settings for plugging the gaps in service deliv- ment may be dangerous for the health of the program in
ery, when skilled personnel cannot be deployed for any the long run. It is though hoped that the provinces will
reason [21]. soon strategize for the fate of the programme funding,
there is a visible unrest amongst the workforce, which is
Health system research affecting the day to day services to the poor and remote
The LHWs program wider reach and numbers of LHWs communities.
available can be made part of a workforce that could be
regularly used as team for health system research. Political and social environment
In some parts of the country there is non-acceptance of
Women empowerment female gender to hold sway. Recent killings of some
The program can be used as a springboard for the com- LHWs in anti-polio campaigns are alluding to ominous
munity women empowerment. LHWs can very well future [25]. Even though the program’s focus is maternal
organize the community by developing women groups and child health care, yet LHWs have to face difficulties
and Health committees in their area -an important as- owing to traditional gender norms in many parts of the
pect of the primary health care approach [22]. LHWs country [26].
themselves have emerged as community leaders in a
context where women are given minimal space in the Non-acceptance by established professions
local politics. The established professions of doctors, nurses, lady
health visitors may act as obscurantist forces in the pro-
Strengthening referral system gress of the program.
One of the weaknesses of the primary health care pro-
gram has always been its poor and weak referral system. Quackery
LHWs can be instrumental in strengthening the referral Lady Health Workers may fall prey to the temptation of
of vulnerable patients particularly the women and chil- inappropriate practices in the private sector that may
dren to ensure timely and appropriate health care seek- erode public confidence in the program.
ing to save lives [23].
Discussion
d) THREATS: Threats are depicted in panel 4. The government has so far shown a great deal of polit-
ical commitment for the continuity of the program. It
Panel 4: THREATS has been proved to be a cost effective venture to make
the primary health care at the doorstep of the poor, re-
 Poverty, patriarchy and social norms mote and rural population. The program by virtue of its
 Political interference comprehensive design, planning, implementation and
 Lack of funds supervision mechanisms aided by an MIS, can deliver
 Political and social environment results even better now in the post devolution scenario,
 Non-acceptance by established medical professions whereby provinces now have a direct control over the
 Quackery implications personnel of the program. This program has the potential
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to improve the health indicators and creating an impact at Acknowledgements

the primary health care level in the health system of Authors are grateful to the management of Health Services Academy and
the PhD programme for providing the insights into the idea of this
Pakistan [27]. However, a referral system will have to be manuscript and for providing access to the library resources.
formalized and incentivized. Nonetheless, such an exten-
sive community based program has a definite potential to Author details
1
Department of Community Medicine, Ayub Medical College, Abbottabad,
improve the mother and child survival as has been dem- Pakistan. 2Department of Health Systems & Policy, Health Services Academy,
onstrated in other parts of the world, yet the weaknesses Islamabad, Pakistan.
in the program ought to be addressed to take the best
Received: 11 October 2013 Accepted: 21 November 2013
productivity out of the community based health workers Published: 22 November 2013
[28]. The provinces must work on widening the coverage
of services, and invest on its potential contribution to
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doi:10.1186/1742-4755-10-60
Cite this article as: Wazir et al.: National program for family planning
and primary health care Pakistan: a SWOT analysis. Reproductive Health
2013 10:60.

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