LHW Punjab and ICT Report - Oxford Policy Management

Lady Health Worker ProgrammeExternal Evaluation of theNational Programme forFamily Planning andPrimary Health CarePunjab and ICT SurveyReportOxford Policy ManagementMarch 2002

Reports from this Evaluation1. Final Report2. Quantitative Survey Report3. Financial and Economic Analysis4. Punjab and ICT Survey Report5. Sindh Survey Report6. NWFP and FATA Survey Report7. Balochistan Survey Report8. AJK and FANA Survey ReportWhite Cover Reports9. Training Programme Review10. Qualitative Report11. Survey Sampling Design12. Quantitative Survey QuestionnairesCover Photo: Enumerator conducting household survey

ACKNOWLEDGEMENTSThis evaluation of the National Programme for Family Planning and Primary Health Carewas undertaken by Oxford Policy Management, UK and funded by the Department forInternational Development, UK.The core evaluation team included, in alphabetical order: Shafique Arif (SurveyManager); Dr. Abdul Ghaffar (Systems Analysis & Dissemination); David Hoole (Financial& Expenditure Study); Simon Hunt (Team Leader); Prof. Fehmida Jalil (Training Systems);Peter Miller (Research Strategy); Georgina Rawle (Financial & Expenditure Study); Dr. ZebaSathar (Research Strategy & Qualitative Field Work); Dr. Sameen Siddiqi (SystemsAnalysis); Dr. Catriona Waddington (Technical Team Leader – pro-tem); Patrick Ward(Survey Design and Analysis); Philippa Wood (Institutional & Organisational Analysis;Dissemination Strategy).This report is based on the results of the Quantitative Surveys. The Federal Bureau ofStatistics provided the control sample. Patrick Ward managed the design and analysis of thesurveys. Other members of the OPM evaluation team assisted in the design of the survey andquestionnaires, particularly Simon Hunt and Juan Munoz. A team of analysts worked on theanalysis and report writing. They were: Shafique Arif, Bianca Camac, Ludovico Carraro,Megan Douthwaite, Simon Hunt, Nils Riemenschneider, Patrick Ward and Philippa Wood.The Population Council, Islamabad, was responsible for field implementation anddata processing and provided assistance in the design and piloting of the questionnaires.Shafique Arif was the survey manager for the field operation and Minhaj ul Haque wasresponsible for data processing. Mehmood Asghar provided invaluable support with desktoppublishing. A large team of supervisors, enumerators and others worked on the survey andare listed in the Quantitative Survey Report. The evaluation team would like to thank all ofthem for the hard work put into the survey. The cooperation and assistance provided by staffmembers of the National Programme for Family Planning and Primary Health Carethroughout the country, including the Lady Health Workers and their supervisors, is alsogratefully acknowledged, as is the cooperation of the householders, community members andhealth facility staff interviewed.

TABLE OF CONTENTSABBREVIATIONS ..................................................................................................................................................................... VEXECUTIVE SUMMARY......................................................................................................................................................... VIICHAPTER 1 EVALUATING THE LADY HEALTH WORKER PROGRAMME .......................................................................1The Lady Health Worker Programme .........................................................................................................2Lady Health Worker Programme Evaluation ..............................................................................................2Characteristics of the Lady Health Worker and her Supervisor ..................................................................3Key Points ...................................................................................................................................................3CHAPTER 2 PROVIDING SERVICES TO THE DOORSTEP..................................................................................................5Levels of Service Delivery ..........................................................................................................................6Delivery of Curative Services......................................................................................................................7Activities in the Community........................................................................................................................8Referral to Health Facilities.........................................................................................................................8Key Points ...................................................................................................................................................9CHAPTER 3 LEVELS OF PERFORMANCE ..........................................................................................................................11Performance of Lady Health Workers in Service Delivery .......................................................................12Performance in the Community................................................................................................................13Explaining High Performance ...................................................................................................................13Improving Service Delivery ......................................................................................................................14Key Points .................................................................................................................................................15CHAPTER 4 THE LADY HEALTH WORKER BUSY AT WORK?........................................................................................17Client Registration.....................................................................................................................................18Time Spent Working .................................................................................................................................18Household Visits Made and Clients Seen..................................................................................................19Taking on Additional Paid Work...............................................................................................................20Key Points .................................................................................................................................................21CHAPTER 5 KNOWLEDGE, SKILLS AND TRAINING OF LADY HEALTH WORKERS AND THEIR SUPERVISORS..23The Knowledge Test..................................................................................................................................24

Knowledge Test Results ............................................................................................................................24Analysing the Results ................................................................................................................................25Scoring Well on the Knowledge Test........................................................................................................25Improving Knowledge Through Training..................................................................................................26Key Points .................................................................................................................................................27CHAPTER 6 SUPERVISION OF LADY HEALTH WORKERS AND THEIR SUPERVISORS.............................................29Managing Performance Through Supervision...........................................................................................30Supervision of Lady Health Workers ........................................................................................................30Supervision of Lady Health Supervisors ...................................................................................................31Supervisors’ Workload and Work Patterns................................................................................................31Transportation............................................................................................................................................32Key Points .................................................................................................................................................33CHAPTER 7 PAY AND PROVISIONS- MEDICAL SUPPLIES AND EQUIPMENT .............................................................35Performance of the Pay System.................................................................................................................36Supply of Medicines and Equipment.........................................................................................................36Improving Distribution and Supply ...........................................................................................................38Key Points .................................................................................................................................................38APPENDICESAppendix 1: The Quantitative Survey ...................................................................................................40Appendix 2:Appendix 3:Appendix 4:Demographic and Educational Characteristics of LHWs and their Supervisors...............41Service Delivery of Lady Health Workers- by Province..................................................43Creating a Measure of Performance for Lady Health Workers.........................................45Appendix 5: Levels of Performance ......................................................................................................46Appendix 6:Lady Health Worker Activities and Population Coverage................................................47Appendix 7: The Knowledge Test .........................................................................................................49Appendix 8: The Knowledge Test Results ............................................................................................53Appendix 9:Training of Lady Health Workers and Lady Health Supervisors......................................56Appendix 10: Supervision .......................................................................................................................59Appendix 11:Work Planning and Reporting...........................................................................................61ii

Appendix 12:Appendix 13:Transportation for Supervisors..........................................................................................62Supplies of Medicines and Equipment..............................................................................63FIGURESFigure 2-1Lady Health Workers Average Coverage of Preventive and Promotive Services toEligible Individuals.............................................................................................................6Figure 3-1 Lady Health Worker Provision of Service by Performance Category ..............................12Figure 3-2Figure 4-1Performance of Punjab and ICT Lady Health Workers in each PerformanceCategory Compared to Nation-wide .................................................................................13Average Number of Persons Registered with the Lady Health Worker............................18Figure 4-2 Average Number of Hours Worked Last Week by Lady Health Worker .........................19Figure 4-3 Allocation of Work Time by Lady Health Workers in Punjab and ICT ...........................19Figure 4-4 Average Number of Household Visits made last Week by Lady Health Worker .............20Figure 4-5Average Number of Clients seen last Week by Lady Health Worker...............................20Figure 4-6 Proportion of Lady Health Workers with Another Paid Job .............................................21Figure 5-1Figure 5-2Figure 6-1Figure 6-2Figure 6-3Knowledge Score for Lady Health Workers and Supervisors...........................................24Relationship between the Knowledge Score and the Level of Education of LHWsand Supervisors- Nation-wide...........................................................................................26Percentage of Lady Health Workers Visited by Supervisor in the Past Month.................30Percentage of Lady Health Workers who have attended the Monthly Meeting atTheir Health Facility in the Past Sixty Days .....................................................................31Allocation of Lady Health Supervisors’ Work Time in Punjab and ICT..........................32Figure 6-4 Percentage of LHSs with Full or Partial Access to a Vehicle in the Past Month ..............33Figure 7-1Figure 7-2Percentage of LHWs’ Paid within the Past Two Months..................................................36Percentage of LHWs without Manuals and without Weighing Scales..............................37TABLESTable 2-1Table 3-1Consulting the Lady Health Worker for Illness or Injury- by Province..............................8Carrying out Community Level Activites-by LHW Performance Category.....................13Table 3-2 Variation in Non-Programme Factors by LHW Performance Category ...........................14Table 7-1 Lady Health Worker’s Stock of Medicines- Punjab and ICT ...........................................37Table A. 1.1 Sample sizes for Final Analysis ........................................................................................40iii

Table A. 2.1Table A. 2.2Demographic and Educational Characteristics of Lady Health Workers..........................41Demographic and Educational Characteristics of Lady Health Supervisors.....................42Table A. 3.1 Lady Health Workers Preventive and Promotive Services by Province ...........................44Table A. 5.1Table A. 6.1Table A. 6.2Table A. 6.3Table A. 6.4Table A. 7.1Table A. 7.2Table A. 8.1Table A. 8.2.Table A. 9.1Table A. 9.2Table A. 10.1Table A. 10.2Table A. 10.3Table A. 11.1Table A. 11.2Table A. 12.1Table A. 13.1Different Levels of Performance amongst Lady Health Workers.....................................46Number of Households and Persons Registered by Lady Health Workers.......................47Number of Hours Lady Health Workers Worked Last Week by Type of Activity...........47Days Worked by Lady Health Workers During Last Week..............................................48Number of Household Visits Made and Number of Clients Seen during the PastWeek as Reported by the Client........................................................................................48Scoring for General Knowledge section of the Knowledge Test.......................................50Scoring for Case-based Section of the Knowledge Test....................................................51The Knowledge Test-General Knowledge Section. Percentage of Correct Answersgiven by LHWs and Supervisors, Nationally and in Punjab & ICT..................................53The Knowledge Test-Case Based Questions. Percentage of Correct Answers givenby LHWs and Supervisors, Nationally and in Punjab & ICT ...........................................54Training Received by Lady Health Workers.....................................................................57Training Received by Lady Health Supervisors................................................................58Supervision of Lady Health Workers................................................................................59Supervision of Lady Health Supervisors...........................................................................59Lady Health Supervisors Workloads and Working Patterns.............................................60Lady Health Worker Work Planning and Reporting.........................................................61Lady Health Supervisor Work Planning and Reporting....................................................61Transportation for Supervisors..........................................................................................62Lady Health Worker Stock of Medicines- Nation-wide....................................................63Table A. 13.2 Percentage of Lady Health Workers with Functional Equipment andAdministrative Materials...................................................................................................63iv

ABBREVIATIONSAJKBHUEPIFANAFATAFLCFFPOFPIUGOPHMISICTLHSLHWLHWPMCHMoHNAsNWFPPHCPOLPSUPPIURHCAzad Jammu and KashmirBasic Health UnitExpanded Programme of ImmunisationFederally Administered Northern AreasFederally Administered Tribal AreasFirst Level Care FacilityField Programme OfficerFederal Programme Implementation UnitGovernment of PakistanHealth Management Information SystemIslamabad Capital TerritoryLady Health (Worker) SupervisorLady Health WorkerLady Health Worker ProgrammeMother and Child HealthMinistry of HealthNorthern Areas (FANA)North Western Frontier ProvincePrimary Health CarePetrol, Oil and LubricationPrimary Sampling UnitProvincial Programme Implementation UnitRural Health Centrev

EXECUTIVE SUMMARYOver the past seven years the Lady Health Worker Programme (LHWP) has become animportant element in the Government of Pakistan’s plan to raise the health status of womenand children in villages and poor urban areas. Over thirty million people are receivingservices from a Lady Health Worker (LHW) in their community. The evaluation shows thatthese services have a positive impact on the health of the poor, particularly women andchildren. Through their work, LHWs are contributing directly to improved hygiene andhigher levels of contraceptive use, iron supplementation, growth monitoring and vaccinationamongst their clients. Almost three out of four communities report that the LHWP hasgenerally improved people’s lives.This report presents information on the performance of the LHWP in Punjab and ICTthat has been collected mainly through the quantitative surveys that form part of an externalevaluation.Service DeliveryThe proportion of eligible clients receiving services provided by LHWs varies according tothe type of service being provided. About forty percent of the LHWs clients in Punjab andICT are receiving the preventive and promotive services for which they are eligible. Indelivering these services the LHW should be visiting all of her registered households eachmonth – in Punjab and ICT this would mean visiting an average of thirty-nine households perweek. The average Punjabi and ICT Lady Health Worker is visiting around thirty householdsper week- the highest level across the country. However at this rate she would still not bevisiting all of her registered households in a month. In addition twenty-six percent of herhouseholds had not received a visit in the past three months.LHWs in Punjab and ICT do provide a higher level of service than average to theirclients, in discussing family planning with non-users and with current users who are notsupplied by the LHW and in encouraging vaccination of children. However LHWs in thePunjab and ICT need to increase their level of service in promoting hygiene and ways toreduce diarrhoea, improving cleanliness of drinking water, growth monitoring and providingnutritional advice. The LHW could also become a larger supplier of contraceptives if she hadthem to distribute.In addition to providing preventive and promotive services, LHWs’ report thatcurative services are an important part of their workload and that many of them see patientswith emergencies. The LHW is also expected to refer patients to the health facilities.Unfortunately clinical support services at the health facilities throughout the country areinadequate and this would be expected to limit the effectiveness of the LHWs referral role.Differing Levels of PerformanceLady Health Workers can be classified as High Performers, Good Performers, BelowAverage and Poor Performers. High Performing LHWs provide nearly seventy percent oftheir eligible clients with relevant services. Poor Performers on the other hand, are providinga service covering barely twenty percent of their eligible clients. In Punjab and ICT twentythreepercent of LHWs are High Performers and twenty-two percent are Poor Performers

compared to twenty-five percent in each category nation-wide. The Programme needs towork with the Poor Performers to substantially increase their level of service delivery.Thirteen percent of LHWs in Punjab and ICT have additional paid work. This doesnot however cause poor performance as we have found that High Performers are more likelyto have a second job than Poor Performers.The Knowledge TestThe Evaluation Team developed a Knowledge Test based on the LHW manual. LHWs whowere High Performers in service provision tended to get better test results. In addition, wefound that the higher the education of the LHW and the Lady Health Supervisor (LHS), thehigher the score. This means that it is important the Programme does not lower its educationcriteria if it wants to maintain performance.Across the country, the knowledge of the LHW and their Supervisors is high in manyareas. LHSs in AJK and FANA score the highest in the country on the Knowledge Test withan average score of seventy-seven percent. On average LHWs in Punjab and ICT scoreseventy-percent compared the national average of sixty-nine percent.The low scores and lack of in-depth knowledge of a minority of LHWs could haveserious clinical consequences as well as undermining the professional reputation of theProgramme. The Programme needs to ensure an on-going system of knowledge assessmentand reinforcement for all LHWs.Organisational Support- Supervision, Pay and SuppliesOn average, Supervisors in Punjab and ICT manage twenty-eight LHWs. Five percent ofLHWs in Punjab and ICT do not currently have a Supervisor. The majority of LHWs inPunjab and ICT had received at least one visit from their supervisor in the past month andhad attended a monthly meeting at the health facility in the past two months. On average, inthe previous month Supervisors in Punjab and ICT had worked twenty-three days. Howeverinsufficient access to vehicles and lack of sufficient POL allowance is hindering fieldsupervision. Only sixty-seven percent of LHSs in Punjab and ICT reported having full-timeor partial access to a LHWP vehicle in the month preceding the survey. LHSs who did nothave vehicles did use public transport but this is not a perfect substitute for vehicle access.Lady Health Workers and their supervisors should receive their pay monthly. InPunjab and ICT only thirty-five percent of LHWs had received their pay in the past twomonths and forty-two percent had not been paid in over three months. The results are similarfor Supervisors. The pay system at the time of the survey was not working well.Medical supplies and equipment are essential in ensuring an effective communityhealth service. Also the credibility of an LHW amongst her community will also beundermined if she is unable to distribute contraceptives and other medicines as expected.Numerous medicines had not been available for the Punjabi and ICT Lady Health Worker’smedicine kit during the previous three months. Supplies are not arriving at the healthfacilities for distribution. This problem has a number of causes including distribution fromProvincial stores and insufficient supplies being purchased by the FPIU. In Punjab and ICT,nine percent of the Lady Health Workers did not have a LHW manual, which is an importantviii

ongoing reference source for the LHW and should be available and up-to-date. Twenty-fourpercent of Punjabi and ICT Lady Health Workers did not have both weighing scales andgrowth monitoring cards- tools important in conducting growth monitoring.High Performing LHWs have higher levels of knowledge, are better supervised andbetter supplied with drugs and equipment than other LHWs. On this basis the programmeneeds to improve its organisational support across the programme to all LHWs.Improving PerformanceThe Ministry of Health has done well in establishing the LHWP and the High Performersdemonstrate the level of service delivery that is possible. The challenge now is to increase thelevel of services provided by the majority of LHWs and particularly the Poor Performers inorder to maximise health services to the poor and provide value for money. Performanceindicators, which direct attention at service delivery, need to be developed and utilised by theLHWP.Through the evaluation we were able to identify key areas where organisationalimprovements could result in a significant increase in service delivery through existingLHWs. We know that supervision is an important lever for improving performance.Supervision would be strengthened significantly if the Programme ensured that Lady HealthSupervisors had access to a vehicle for supervision. Programme performance will alsoimprove if the knowledge of the LHW is increased in line with the curriculum. In additionPoor Performers need to be dealt with. Where LHWs are unable or unmotivated to provide aservice then it would be better for the community if they were replaced.The Lady Health Worker Programme provides an important service to the women andchildren of poor communities in Pakistan. The Federal Programme Implementation Unit(FPIU) and the Provincial Programme Implementation Units (PPIUs), along with theMinistry of Health (MoH) and the Departments of Health (DoH) in the Punjab and ICT, allneed to maintain the strength of the Programme and address the weaknesses outlined in thisreport.ix

Chapter 1EVALUATING THE LADYHEALTH WORKER PROGRAMMEIN THIS CHAPTER:• The Lady Health WorkerProgramme• The LHWP Evaluation• Characteristics of the Lady HealthWorker and her Supervisor• Key Points

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTTHE LADY HEALTH WORKER PROGRAMMEThe Lady Health Worker Programme (LHWP) has become an important element in theGovernment of Pakistan’s plan to raise the health status of women and children in ruralvillages and poor urban areas. The Programme was conceived in 1993 and launched in April1994 as a Federal development programme funded by the Ministry of Health (MoH), andimplemented by both the MoH and the provincial Departments of Health.The main goal of the programme was to establish a primary health care service:• providing accessible promotive, preventive, curative and rehabilitative services to theentire population• bringing about community participation• improving the utilisation of health facilities• expanding availability of family planning services in urban slums and rural areas ofPakistan, and• gradually integrating existing health care delivery programmes like EPI, Malaria control,Nutrition, MCH within the programme. 1LADY HEALTH WORKER PROGRAMME EVALUATIONThis report 2 presents information, collected mainly through quantitative surveys, as a part ofan external evaluation, on the performance of the LHWP in Punjab and ICT. 3It covers:• the characteristics of LHWs and their Supervisors• the range and level of preventive, promotive, curative and referral services provided bythe LHW.• the difference between high performing and poor performing LHWs• the activities of the LHW including hours of work and the number of registered clients,• the knowledge and skills levels that the LHW and her supervisor bring to their jobs• the quality of the organisational support received by the LHW and the LHS.This information should support programme managers in Punjab and ICT and at theFederal level, to identify initiatives to improve programme performance through raising thequality and level of service delivery.1Ministry of Health- Government of Pakistan Prime Minister’s Programme for Family Planning and Primary Health Care-Revised PC-1, August 1995- page 3.2This report is one of a series of eight reports providing the results of the evaluation. Provincial and FederallyAdministrated Area reports have also been written for Punjab and ICT, NWFP and FATA, AJK and FANA, andBalochistan. In addition there are three national level reports: the Final Report which addresses key policy, servicedelivery and management issues; the Quantitative Survey Report providing an extensive analysis of the quantitativeresults; and The Financial and Economic Analysis presenting costs and spending patterns of the LHWP. In addition tothese reports there are four white cover reports: the Training Programme Review, the Qualitative Report, the SurveySampling Design and the Quantitative Survey Questionnaires.3See Appendix One and the Quantitative Survey Report for further information on the quantitative surveys.2

EVALUATING THE LADY HEALTH WORKER PROGRAMMECHARACTERISTICS OF THE LADY HEALTH WORKER AND HERSUPERVISORThe Programme has specific recruitment criteria for Lady Health Workers and theirSupervisors. It is important for Programme credibility and reputation as a professional servicethat these criteria, once determined, are adhered to. 4Age and Marital Status: LHWs should be between twenty and fifty years old,though if married eighteen and nineteen-year-olds are acceptable. Punjabi and ICT LHWsmet these criteria. The majority of Punjabi and ICT Lady Health Workers, sixty-threepercent, are currently married as preferred by the programme. The Supervisors, bothnationally and in Punjab and ICT, are also typically in their late twenties and just over half ofthem are married.Education: LHWs should be educated to at least the eighth class, though it ispreferable for them to be matriculated. Based on LHWs own reports, Punjabi and ICT LadyHealth Workers have an education of at least an 8 th class pass and fifty-five percent haveclass ten or above. Over eighty percent of LHWs in Punjab and ICT could confirm classachievement through showing their school certificate. While the selection criteria forsupervisors requires at least a class 10 pass, in practice most supervisors are considerablybetter qualified. In Punjab and ICT over half of the supervisors have at least graduateeducation.LHW Residence: The vast majority of LHWs live in the village/ mohalla in whichthey work, as required by Programme standards. Nationally four percent are non-residents. InPunjab and ICT it is just over three percent. LHWs are very much part of the community theywork in. In Punjab and ICT forty-seven percent of the LHWs were born within thecommunity and a further forty-six percent have been resident for more than five years.The Programme in Punjab and ICT has been successful in ensuring that the vastmajority of LHWs and their Supervisors meet the educational, age and residency criteria.KEY POINTS• The Lady Health Worker Programme (LHWP) has become an important element in theGovernment of Pakistan’s plan to raise the health status of women and children invillages and poor urban areas.• This report presents information, collected mainly through quantitative surveys on theperformance of the LHWP in Punjab and ICT.• The Programme has been successful in ensuring the vast majority of LHWs and theirSupervisors meet the educational, age and residency criteria.4 See Appendix 2 and the Quantitative Survey Report for more information.3

Chapter 2PROVIDING SERVICESTO THE DOORSTEPIN THIS CHAPTER:• Levels of Service Delivery• Delivery of Preventive andPromotive Services• Delivery of Curative Services• Activities in the Community• Referral to Health Facilities• Key Points

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTLEVELS OF SERVICE DELIVERYOur survey shows that over thirty million people in Pakistan are receiving services from theLHW 5 and that these services are making a difference. LHWs are providing health services tothe poor, particularly women and children, which contribute directly to higher levels ofcontraceptive use, vaccination in children, better hygiene behaviour, iron supplementation,antenatal care and growth monitoring amongst their clients. 6The range of services that LHWs provide to their clients include:• 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• Promoting and facilitating vaccinationFigure 2-1 Lady Health Workers Average Coverage of Preventive and PromotiveServices to Eligible Individuals% of eligible individuals receiving servicefrom LHW60504030201004943393732Punjab & ICT Sindh NWFP & FATA Balochistan AJK & NAsFor many services across the country, and for most of the promotive services,between forty to fifty percent of eligible clients have been provided with the service. 7 Theaverage coverage across all services is thirty-nine percent in Punjab and ICT (Figure 2-1).LHWs AJK and Northern Areas provide the highest coverage across a range ofservices and those in Balochistan provide the lowest. 8 The level of provision varies betweenprovinces 9 and with the type of service.56789See Quantitative Survey Report for calculation on number of LHWs in the field.See Quantitative Survey Report for information on the impact of the LHW on health outcomes.See Appendix 3: Service Delivery of Lady Health Workers for levels of service provision.The main exception to this is the LHWs important role in Balochistan in contraceptive supply, which presumably reflectsa lack of other sources of contraceptives.‘Province’ is used throughout the report to refer to both Provinces and Federally Administrated Areas.6

PROVIDING SERVICES TO THE DOORSTEPPunjab & ICT Lady Health Workers do better than average in providing the followingservices: 10• discussing family planning with non-users and current users who are not supplied by theLHW• talking to mothers about vaccinating their child and encouraging them to take the childfor vaccination at the necessary age.These are important services. The evaluation has shown that contraceptive use and thelevel of children vaccinated has generally increased where LHWs are working.Services, which are not so well supplied in Punjab and ICT, include:• talking with households about improving hygiene, reducing diarrhoea and improving thecleanliness of the drinking water.• visiting the newborn babies and weighing them• giving advice on feeding children under three• supplying current users with modern contraceptivesIt is important to increase the level of these services because we have found in theevaluation that where the LHW has promoted the use of clean drinking water or betterhygiene behaviour there are lower levels of diarrhoea. Very little growth monitoring isundertaken Nation-wide however the level is even lower in Punjab and ICT. While there areproblems with regular supply of contraceptives – it may also be that in Punjab and ICT thereare a larger number of alternate suppliers available.Across the country LHWs are playing an important role in family planning provision.While it was not expected that the LHWs family-planning service would be ascomprehensive as other services, we found in Punjab and ICT, thirty percent of users say thatthey are supplied or were referred by the LHW, and a full forty percent of pill and condomusers obtained their last supply from the LHW. These are similar to the national figures.These results represent a substantial achievement by the Programme in providingbasic primary health care to the population. However around fifty-sixty percent of the clientsin LHW areas are not being provided with many of the services they are supposed to receiveand a higher proportion still fail to receive some particular services. Even in areas with higherlevels of service coverage it should still be possible with improved programme management,to increase the level of services provided to clients and maximise the impact on health whilestill providing value for money. 11DELIVERY OF CURATIVE SERVICESThroughout the country LHWs are an important source of consultation for individuals whoare sick or injured – one fifth of them consulted the LHW if they consulted anyone at all. Theresult is similar for Punjab and ICT (Table 2-1).10 See Appendix 3: Service Delivery of Lady Health Workers by Province.11 Specific suggestions for improvement are made later in this report and in the other Evaluation Reports.7

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTInformation provided by LHWs confirms that curative services are an important partof their workload. Indeed, well over half of the cases seen by LHWs are curative rather thanpreventive. This might be due to LHWs being more likely to report a client who was ill thanto report the delivery of routine preventive services. Treating fever and respiratory infectionsand routine family planning visits were the most commonly reported activities.Table 2-1 Consulting the Lady Health Worker for Illness or Injury- by ProvinceMeasurePunjab& ICTSindh NWFP& FATABalochistanAJK& NAs% of individuals who were ill or injured in theprevious fourteen days who consulted theLHW –if they consulted anyone at all:20 13 18 18 32LHWs were also asked to report on the last emergency case seen – that is, the lastcase that they saw who required immediate referral to a health facility. Throughout thecountry, almost nineteen percent had never seen such a case. Presumably this reflects the useof other providers. For those who had seen an emergency case, complications of delivery andpregnancy, together with respiratory infections and severe dehydration, were the mostcommon. This suggests that LHWs are playing a useful role in the identification and referralof serious cases.ACTIVITIES IN THE COMMUNITYThe LHW is responsible for mobilising the community to promote and improve healththrough her participation in the health committee and in the women’s health committee.While across the country these committees are not taking off, there is a positive perception ofthe work of most LHWs. In Punjab and ICT, four out of five communities reported that theLHW has generally improved people’s life in the village and eighty-nine percent reportedthat once the women had become an LHW, she was usually respected.REFERRAL TO HEALTH FACILITIESOne objective of the LHWP was to improve the utilisation of public health facilities throughclient referrals. Private facilities are often not accessible in rural areas or are too expensivefor the poor to afford. Adequate publicly provided services that are either free or cheap at thepoint of delivery are therefore an important part of improving community health.Unfortunately, nation-wide, staffing and supplies at the health facilities that theLHWs are attached to are often very poor and some of the communities where LHWs workare under-served by vaccination services. 12 We found clinical support services on whichLHWs depend are inadequate which would limit the effectiveness of the LHWs referral role.12 See the Quantitative Survey Report for information on services at health facilities.8

Chapter 3LEVELS OF PERFORMANCEIN THIS CHAPTER:• Performance of Lady HealthWorkers in Service Delivery• Performance in the Community• Explaining High Performance• Improving Service Delivery• Key Points

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTPERFORMANCE OF LADY HEALTH WORKERS IN SERVICE DELIVERYWe have developed a performance measure of LHW service delivery using a selection of tenpreventive services. 13 These cover LHW activities in, hygiene, health education, vaccinationpromotion, family planning, pregnancy and birth, child nutrition and growth monitoring.Using our measure of performance we find major differences in the levels of service deliveryamongst LHWs. The top 25 percent - the High Performers provide significantly moreservices than the bottom 25 percent- the Poor Performers. In between we have the GoodPerformers and those who are Below Average.Figure 3-1 Lady Health Worker Provision of Service by Performance Category% target population provided services100908070605040302010017Poor Performers35Below AveragePerformers4868Good Performers High PerformersOn our performance measure the Poor Performers are on average only providingservices to seventeen percent of their eligible clients as compared to the High Performers whoprovide on average services to sixty-eight percent (Figure 3-1). It is easy to distinguish PoorPerformers because they fail to deliver across the whole range of services whereas HighPerformers cover at least sixty percent of clients 14 - and often well above this - for allservices, except growth monitoring. 15 High Performing LHWs are also working longer hours.In the week preceding the survey they had worked over twenty-two hours compared toseventeen for poor performers.In Punjab and ICT twenty-three percent of LHWs are in the high performing categoryand twenty-two percent are Poor Performers (Figure 3-2). The challenge for the LHWPmanagers is to improve the performance of the fifty- percent of Poor and Below AveragePerformers.13 See Appendix 4 and the Quantitative Survey Report for a description of the performance measure of LHW servicedelivery.14 See Appendix 5 for more information on different levels of performance amongst Lady Health Workers.15 The low level of growth monitoring even in the relatively high performing LHWs suggests that there are specificproblems that need to be addressed if the Programme considers it important to offer this service.12

LEVELS OF PERFORMANCEFigure 3-2 Performance of Punjab and ICT Lady Health Workers in each PerformanceCategory Compared to Nation-wideLHWs in each performance category40%30%20%10%0%PoorPerformersBelowAverageGoodPerformersHighPerformersPunjab/ ICT 22% 28% 27% 23%National Average 25% 25% 25% 25%PERFORMANCE IN THE COMMUNITYHigh Performing LHWs are more involved with the community with fifty-seven percent ofcommunities they cover reporting that there is a functioning health committee (Table 3-1).Table 3-1 Carrying out Community Level Activites-by LHW Performance CategoryBelowPoorGoodMeasureAveragePerformersPerformersPerformersHighPerformers% of communities who report that there is afunctioning Health Committee 28 37 43 57% of LHWs who report that they have beento talk to children at the local school 70 89 82 94EXPLAINING HIGH PERFORMANCEWe tested many factors to identify those that explain the large variations in LHWperformance. 16 We found that nationally, High Performers have a higher level of knowledge,are better supervised and are better supplied with medicines and equipment. The supervisorsof High Performers also have higher levels of knowledge, are more likely to have been fullytrained and have access to a programme vehicle for field supervision.The argument that unmarried women will not be so accepted by the community, andtherefore less able to provide a service, may be true in particular communities but does notseem to be supported overall. We found that Poor Performers are, if anything slightly morelikely to be married.16 For a full explanation of the analysis see the Quantitative Survey Report.13

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTHigh performing LHWs are also more common in environments where women aremore mobile, 17 and there are more LHWs classified as Poor Performers working indisadvantaged areas (Table 3-2). 18Table 3-2 Variation in Non-Programme Factors by LHW Performance CategoryBelowPoorGood HighMeasureAveragePerformersPerformers PerformersPerformers% of women (15-49 years) who can go aloneto clinic/hospital outside the village*38 42 44 48% of households that have a toilet* 59 64 65 65* in households registered with the LHWIMPROVING SERVICE DELIVERYWhat are some key areas where the Programme can improve performance? 19 The EvaluationTeam found it would be possible to achieve a significant improvement in service delivery ifSupervisors were provided with transport and if LHW scores on the Knowledge Test 20 wereimproved to an average of eighty percent.These goals would require action from both the Federal Programme ImplementationUnit (FPIU) and the Provincial Programme Implementation Units (PPIUs) along with strongsupport from the Ministry of Health (MoH) and the Punjab and ICT Departments of Health.We do not have performance information by District, however the results from thesurveys and from stakeholder consultations point to the importance of the District HealthManagement in the ensuring the effective functioning of the Programme. A good District Coordinatorwill be able to support high levels of performance from LHWs by being active in:• finding solutions to Supervisor’s transport problems,• ensuring high quality training is provided for LHWs and their Supervisors• monitoring the Supervisor’s field activities• bringing logistic problems to the attention of senior Programme Management. 21To improve performance, Programme Management must also target and deal withnon-performance. There needs to be safeguards to prevent abuse – LHWs should not havetheir contracts terminated if they meet the Programme criteria, are knowledgeable andperforming well. However, if after support has been given to a Poor Performer, and if theyare unable or not motivated to provide a service then it would be better for the community ifthey were replaced.17 As measured by the number of women who report that they could go alone to a health facility outside the village.18 As measured by access to a toilet.19 A model was construction and regression methods used to show the variables, which have the strongest relationship withperformance. For a full description of the model and techniques used see the Quantitative Survey Report.20 See Chapter 5. High Performers have greater knowledge and provide a greater level of service coverage.21 There are reports of District Coordinators and Logistics Officers who are not doing this.14

LEVELS OF PERFORMANCEIt is also important that the Programme continue to target the truly disadvantagedareas even though it is harder to achieve high performance in poorer communities andcommunities where women are less mobile.KEY POINTS• There is marked variation in service delivery amongst LHWs between High Performersand Poor Performers. The Poor Performers are barely providing a service.• In Punjab and ICT twenty-three percent of LHWs are in the High Performers, coveringnearly seventy percent of their clients, and twenty-two percent are Poor Performers,covering less than twenty percent.• High Performers have a higher level of knowledge, are better supervised and are bettersupplied with more medicines and equipment. The supervisors of High Performers alsohave higher levels of knowledge, are more likely to have been fully trained and haveaccess to a programme vehicle.• A top priority to increasing Programme performance is to achieve a significantimprovement in access to transport by supervisors and improving LHWs knowledge.• It is important that the Programme continues to focus on providing services to poorercommunities, even if it is more difficult to achieve high service coverage.• Action to improve the Programme is required from the FPIU, the PPIUs and the DPIUs,along with strong support from the MoH and the Punjab and ICT Departments of Health.• The ability of the Programme to target and deal with non-performance needs to beincreased at the LHW level and the District level. There needs to be safeguards to preventabuse – LHWs should not be terminated if they meet the Programme criteria, areknowledgeable and performing well. However, if even after support has been given to aPoor Performer if they are unable or unmotivated to provide a service then it would bebetter for the community if they were replaced.15

Chapter 4THE LADY HEALTHWORKER BUSY AT WORK?IN THIS CHAPTER:• Client Registration• Time Spent Working• Household Visits Made and Clients Seen• Taking on Additional Paid Work• Key Points

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTCLIENT REGISTRATIONLHWs are supposed to serve a population of 1,000 individuals or approximately 200households. Nationally each LHW registers 145 households, on average. In Punjab and ICTthis rises to 169. 22 However, with average household size at just over seven people thenumber of individuals served is a more important indicator of population covered (Figure4-1). Based on LHWs’ own reports, in Punjab and ICT the average number of individualsregistered is 1062. 23 This is above the national average of 980. Punjab and ICT Lady HealthWorkers have performed well in client registration.Figure 4-1 Average Number of Persons Registered with the Lady Health WorkerNumber of persons registered1200100080060040020001062898952855723Punjab & ICT Sindh NWFP & FATA Balochistan AJK & NAsTIME SPENT WORKINGOn average, LHWs work twenty hours a week but in Punjab and ICT this rises to overtwenty-two hours (Figure 4-2). This is around 3¾ hours per day over a six-day workingweek. While there are no specific norms for the amount of time that an LHW should work,the suggestion by the Programmes is that the working week should be five hours per day- sixdays per week. Punjab and ICT had only three percent of LHWs not working in the previousweek compared with eight- percent nation-wide. A variety of reasons were given includingtaking leave, illness and travel. The Programme in Punjab and ICT is doing well in ensuringthat LHWs are working.22 See Appendix 6 for information on LHW activities and population coverage.23 As a check, households selected from the LHWs registers - were asked if they knew the LHW and if she had registered thehousehold. Overall, eighty-three percent of registered households in Punjab and ICT said that this was the case. Thiswould suggest that the average LHW in Punjab and ICT is serving a population of 881 people.18

THE LADY HEALTH WORKER BUSY AT WORK?Figure 4-2 Average Number of Hours Worked Last Week by Lady Health WorkerNumber of hours worked last week30252015105022.513.523Punjab & ICT Sindh NWFP &FATA15Balochistan21AJK & NAsAs might be expected, the largest portion of LHW’s time in Punjab and ICT – andnation-wide, is spent visiting households followed by administrative work (Figure 4-3).Figure 4-3 Allocation of Work Time by Lady Health Workers in Punjab and ICTHealth Committee work3%Adminstration15%Other12%Client at Health House7%Household visits63%HOUSEHOLD VISITS MADE AND CLIENTS SEENHigh Performers throughout the country visit around thirty-five households a week incontrast to Poor Performers who visit only six. At this rate, High Performers wouldpotentially achieve the Programme standard of visiting each of their registered households atleast once a month. In Punjab and ICT, with an average of 169 households registered in eachcommunity served, we would expect the LHW, on average to be making thirty-nine visits perweek. In fact, the average is thirty visits per week (Figure 4-4) with fourteen percent ofLHWs visiting ten households or less. In addition, twenty-six percent of households reportednot having received a visit from their LHW in the past three months.19

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTFigure 4-4 Average Number of Household Visits made last Week by Lady HealthWorkerNumber of household visits last week3530252015105030272115.514Punjab & ICT Sindh NWFP & FATA Balochistan AJK & NAsThe LHWs were also asked how many patients/clients they saw in the week precedingthe survey including those to whom they only gave advice. Nation-wide LHWs reportedseeing twenty clients, on average-in Punjab and ICT it was twenty-two (Figure 4-5).Figure 4-5 Average Number of Clients seen last Week by Lady Health WorkerNumber of clients seen last week3025201510502214.5Punjab & ICT Sindh NWFP &FATA2119Balochistan16AJK & NAsTAKING ON ADDITIONAL PAID WORKDoes taking on additional paid work interfere with performance? This question is particularlyimportant in Sindh because they more than a quarter of LHWs with other paid work (Figure4-6). 24 While it is Programme policy that LHWs should not perform other paid work we24 This is compared to a national average of fifteen percent.20

THE LADY HEALTH WORKER BUSY AT WORK?found that High Performers are more likely to have a second job than Poor Performers,suggesting that holding another job can be compatible with undertaking the duties of anLHW. 25 In undertaking other paid employment LHWs are not complying with programmepolicy. It appears this is not affecting their ability to deliver services. However there may beother policy objectives that could be at risk by some forms of employment. This may be anarea where the Programme should review its policy in the light of these results.Figure 4-6 Proportion of Lady Health Workers with Another Paid Job% of LHWs with another paid job3025201510501326Punjab & ICT Sindh NWFP &FATA910 10BalochistanAJK & NAsKEY POINTS• LHWs in Punjab and ICT register 1062 clients – above the national average of 980. Theyare working over twenty-two hours per week and only three percent had not worked inthe week prior to the survey. This is compared to eight-percent nation-wide.• The LHW in Punjab and ICT is making on average thirty household visits per weekthoughfourteen percent of them are visiting ten households or less. In addition twenty-sixpercent of her households have not received a visit in the past three months.• In the week preceding the survey the LHW in Punjab and ICT had seen twenty-twoclients close to the national average of twenty.• LHWs throughout the country spend most of their time in household visits followed byadministration.• Thirteen percent of LHWs in Punjab and ICT have another paid job.25 The survey did not collect information on what other types of paid work LHWs were engaged in, how many hours theywork or what additional income they received.21

Chapter 5KNOWLEDGE, SKILLS ANDTRAINING OF LADY HEALTHWORKERS AND THEIRSUPERVISORSIN THIS CHAPTER:• The Knowledge Test• Knowledge Test Results• Analysing the Results• Scoring Well on the Knowledge Test• Improving Knowledge through Training• Key Points

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTTHE KNOWLEDGE TESTLHWs and their Supervisors were tested using the Knowledge Test. 26The Knowledge Test is divided into two sections:• general questions covering a range of preventive and curative health care issues,• case histories where the problem must be identified and responded to with the treatmentor advice that would be provided to the patient.A Knowledge Score was arrived at on the basis of how many questions were answeredcorrectly. The score is presented as the percentage of correct answers given against the totalnumber of questions. 27KNOWLEDGE TEST RESULTSThe average score for LHWs in Punjab and ICT was seventy percent compared to the nationwidescore of sixty-nine percent (Figure 5-1). Sindhi LHWs have the highest average score.The Programme in Sindh has reportedly been conducting more testing of LHWs than otherprovinces and this could explain the better results.Figure 5-1 Knowledge Score for Lady Health Workers and Supervisors100% Knowledge Score90807060504074 75 7570 716860636977LHWSupervisor30Punjab &ICTSindhNWFP &FATABalochistanAJK & NAsThe average Knowledge Score for Supervisors in Punjab and ICT was seventy-fourpercent the same as the national average (Figure 5-1). Supervisors in AJK and NorthernAreas had the highest level of knowledge.26 This is a test developed by the Evaluation team to assess LHWs and LHSs work-related knowledge and skills.27 See Appendices 7 and 8 and the Quantitative Survey Report for further information on the Knowledge Test and the results.24

KNOWLEDGE, SKILLS AND TRAINING OF LADY HEALTH WORKERS AND THEIR SUPERVISORSANALYSING THE RESULTSThe level of general clinical knowledge of LHWs and their supervisors is reasonably good.This knowledge however may lack depth, as is shown by the drop in their ability to providemultiple correct responses. 28 There were also some specific areas of weakness. One of theseis knowledge of the vaccination schedule. Only forty-eight percent LHWs in Punjab and ICT(sixty-three percent of their supervisors) could name the four EPI vaccines, give the correctnumber of doses and the correct age at which doses are given. 29There are also serious deficiencies in the ability of LHWs to provide the correct dosesof medicines required in basic situations. Only seven percent of LHWs in Punjab and ICT(ten percent of Supervisors) were able to provide the correct dose of Chloroquine to give to achild with symptoms of malaria, even though they were encouraged to use the Programmemanual or medicine box to answer the question.Performance is much poorer on the case history-based questions. For many questionsover thirty percent of the LHWs, throughout the country, could not give the correct answer.LHWs’ ability to read and interpret child growth cards is also deficient. Only forty-twopercent of LHWs in Punjab and ICT (though eighty-four percent of supervisors) were able toprovide the correct weight of a normal/moderately malnourished child and only twenty-fourpercent (forty-two percent of supervisors) were able to assess that a severely malnourishedchild was failing to gain weight. These results are similar nation-wide and imply that onlyabout thirty to forty percent of LHWs are able to conduct meaningful child growthmonitoring. 30The lack of knowledge of a minority of LHWs could have serious clinicalconsequences to their clients. This needs to be addressed by the Programme.SCORING WELL ON THE KNOWLEDGE TESTFor the LHW, in general, the higher the educational level, the higher will be her score on theKnowledge Test (Figure 5-2).The average score for a LHW with less than eight years of education was fifty-ninepercent while that of an LHW educated to intermediate level was seventy-two percent. As thelevel of knowledge is an important factor in the LHW’s ability to provide quality services,these results suggest that the Programme should maintain its educational criterion for LHWs.We also found that if the LHW had been provided with specific training on growthmonitoring or immunisation, then this was associated with better score on the KnowledgeTest, not only on the particular topic she had been trained in, but overall.Education, training and experience on the job were important factors contributing to aSupervisor gaining a high score. 31 In particular the amount of training received is important.28 See Appendix 8 for the Knowledge Test Results.29 This problem is largely caused by DPT and Polio as there are a large number of doses and ages to remember.30 As we have already seen in Chapter 2 growth monitoring has low coverage Nation-wide including Punjab and ICT.31 Experience could also be important for LHWs. Because our sample are all experienced LHWs this factor does not standout as a variable that makes a difference to their knowledge.25

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTSupervisors who were fully trained scored seventy-five percent on average whereas thosewho had attended only the initial training and not the in-service training scored sixty-fivepercent.Figure 5-2 Relationship between the Knowledge Score and the Level of Education of LHWsand Supervisors- Nation-wide10090Knowledge score807060505969 7071727573 74 75LHWSupervisor4030< 8 yrs 8-9 yrs Matric Intermediate Graduate Post GradHighest level of educationIMPROVING KNOWLEDGE THROUGH TRAININGThe level of clinical knowledge of LHWs and their Supervisors is important in the provisionof a professional and safe service and for the reputation of the LHWP. We have also foundthat LHWs with higher levels of knowledge deliver more services. The main means ofincreasing the knowledge of the current LHWs and Supervisors is through training and onthe-jobcoaching.All LHWs in Punjab and ICT had received their full-time three-month basic trainingcourse at the facilities where they were recruited. The Programme in Punjab and ICT has thendelivered on average eleven months of task-based training. 32 Doctors at the health facilityhave been important in the provision of the training along with the Lady Health Visitor andDispensers. However despite the reasonably high levels of initial training that was providedthere continue to be substantial gaps in LHWs’ knowledge across the country. This suggestsproblems in the quality of the training and/or a failure to reinforce the knowledge imparted. Itmay be in some cases that the trainers themselves did not have sufficient knowledge, orlacked teaching skills particularly in providing experiential training. 33Refresher and on-the-job training needs to be readily available in order to maintainand update knowledge. While most LHWs have received some refresher training in the pastfour years, there would be benefits in providing it more frequently and to a high standard.Supervisors in Punjab and ICT are providing the highest level of training on-the-job to their32 The standard is three months of initial training and twelve months of task-based training.33 See Appendix 9 for more information on training of LHWs and their Supervisor’s.26

KNOWLEDGE, SKILLS AND TRAINING OF LADY HEALTH WORKERS AND THEIR SUPERVISORSLHWs. Sixty-one percent of LHWs in Punjab and ICT report receiving on-the-job trainingcompared to fifty-one percent nationally.We found that further training in growth monitoring and for immunisation days hasbeen shown to improve LHWs knowledge overall but this is not the case with other types ofadditional training she has received which suggest the quality of training needs to beimproved. We also surprisingly found that there was no relationship between the LHWsknowledge score and the level of supervision she received 34 . It appears that the style ofsupervision being provided is not reinforcing the LHWs skills and knowledge. It is importantthat supervisors are fully trained and skilled in providing on-the-job coaching to LHWs andthat they see this as a part of their job.More Lady Health Supervisors in Punjab and ICT have completed their training thanthe national average. Eighty-three percent of LHSs in Punjab and ICT have completed theirfull training programme in contrast to seventy-six percent nationally.The Programme needs to improve the quality and scope of training provided in orderto improve the level of knowledge of LHWs and Supervisors in key functional areas. Thetraining needs to be uniformly imparted with good quality controls, for both LHWs and theirsupervisors.KEY POINTS• The average knowledge score for LHWs and their Supervisors in Punjab and ICT issimilar to the national average.• While LHW knowledge is high in many areas, the lack of in-depth knowledge for aminority of LHWs is of concern. This lack of sufficient depth of knowledge may haveserious clinical consequences as well as undermining the professional reputation of theProgramme. In addition we have found that LHWs who deliver more services- HighPerformers- have higher Knowledge Scores. The Programme must aim to increase theknowledge of both LHWs and their supervisors.• The Programme has been successful in ensuring LHWs and Supervisors attended coretrainingprogrammes, in most Provinces including Punjab and ICT. However trainingneeds to be uniformly imparted across the country with good quality controls andappropriate testing of the knowledge of all LHWs and their Supervisors.• Refresher and on-the-job training needs to be more readily available in order to maintainand update knowledge. The trainers and the supervisors have an important role to play inthis respect. Sixty-two percent of LHWs in Punjab and ICT report receiving on-the-jobtraining from their supervisors compared to fifty-four percent nationally. However thistraining does not seem to be having an impact on Knowledge Scores. It may be that thetraining methods need to be improved.• The level of education of Lady Health Workers and Supervisors is correlated with theirKnowledge Score. The higher the education, the higher the score. It is important that theProgramme does not lower its education criteria if it wants to maintain performance.34 See Quantitative Survey Report.27

Chapter 6SUPERVISION OF LADYHEALTH WORKERS ANDTHEIR SUPERVISORSIN THIS CHAPTER:• Managing Performance throughSupervision• Supervision of Lady Health Workers• Supervision of Lady Health Supervisors• Supervisors Workload and WorkPatterns• Transportation• Key Points

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTMANAGING PERFORMANCE THROUGH SUPERVISIONFrom the evaluation results we know that supervision is the most important lever theProgramme has for improving performance. Supervisors should meet at least once a monthwith the LHW in her community and ideally meet with client households both with, andwithout the LHW. These meetings provide the opportunity to monitor the quality of theLHWs service delivery and her knowledge, and to support good work-planning. The LHWshould also attend a monthly meeting at her local health facility where she can replenish herkit and may receive additional training.The LHS receives her supervision from the District Co-ordinator and should attend amonthly meeting at the District Programme Implementation Unit (DPIU) where she reportson the past month’s work and plans for the following month. Both the LHW and the LHSmay receive feedback from the Field Programme Officer (FPO) who acts as an internalinspector and advisor, and from Programme Management.SUPERVISION OF LADY HEALTH WORKERSNation-wide, ninety-three percent of LHWs have supervisors. This rises to ninety-fivepercent in Punjab and ICT. 35 Given the importance of supervision the Programme needs toensure supervisor posts are kept filled.Ninety-three percent of LHWs in Punjab and ICT had received at least one visit fromtheir supervisor in the past month, as reported by the supervisor (Figure 6-1). This is a goodresult for the Provincial Programme and District Programme Management.Figure 6-1 Percentage of Lady Health Workers Visited by Supervisor in the Past Month% LHWs visited at least once bySupervisor in past 30 days10090807060504030201009385767064Punjab & ICT Sindh NWFP & FATA Balochistan AJK & NAsA high proportion of LHWs in all provinces could produce reports for the previousmonth and four out of five LHWs in Punjab and ICT could show a current work plan. 3635 See Appendix 10 for further information on supervision of LHWs and their Supervisors.36 See Appendix 11: Work Planning and Reporting.30

SUPERVISION OF LADY HEALTH WORKERS AND THEIR SUPERVISORSMonthly meetings at the health facility are well attended. Most LHWs across thecountry will have attended a meeting at least once in the past two months, though the level islower for Sindh and Balochistan (Figure 6-2).Figure 6-2 Percentage of Lady Health Workers who have attended the Monthly Meeting atTheir Health Facility in the Past Sixty Days% of LHWs who had attended a monthlymeeting in the past 60 days10090807060504030201009894958471Punjab & ICT Sindh NWFP & FATA Balochistan AJK & NAsSUPERVISION OF LADY HEALTH SUPERVISORSOnly sixty-four percent of Lady Health Supervisors in the Punjab and ICT had had a meetingwith their supervisor in the past month. This increases to eighty-six percent if we look at theprevious two months. 37 This represents a reasonable level of supervision. The next step inincreasing the quality of supervision is to give the LHS the support needed to deal with poorperformance and to provide better on-the-job coaching for LHWs.SUPERVISORS’ WORKLOAD AND WORK PATTERNSThe original intention of the Programme was that each supervisor would be responsible forthe supervision of thirty LHWs, and that over the life of the project the number supervisedwould fall to fifteen LHWs. Supervisors in Punjab and ICT are responsible on average fortwenty-eight LHWs- close to the national average of twenty-seven. 38 In Punjab and ICTfourteen-percent of Supervisors are responsible for twenty or less LHWs but thirty-sixpercent are responsible for more than thirty.Supervisors in Punjab and ICT reported working an average of twenty-three days inthe past month with just over a half of them working a full month. 39 In the week precedingthe survey, supervisors in Punjab and ICT reported working an average of thirty-one hours.Most of this time (twenty hours) was spent supervising LHWs (Figure 6-3). This includes thetime spent travelling to and from the villages.37 See Appendix 10: Supervision.38 See Appendix 10: Supervision.39 A full month is considered 24 days or more.31

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTFigure 6-3 Allocation of Lady Health Supervisors’ Work Time in Punjab and ICTAdministration14%Other10%Monthly Meetingsat Health Facility8%Individual Meetings3%Field Supervision65%TRANSPORTATIONIn the original design of the Programme, all Supervisors were supposed to have access totheir own vehicle, a driver and an appropriate POL allowance. Transportation is essential forSupervisors for monitoring LHWs and visiting the health facilities and the community. Thisevaluation has shown that increasing access by Supervisors to a vehicle would substantiallycontribute to improving Programme performance. 40In practice, there are large shortfalls in the number of vehicles, and the POL or publictransport allowances do not adequately cover supervisory needs. 41 In the month preceding thesurvey, only sixty-seven percent of Lady Health Supervisors in Punjab and ICT reportedhaving partial or full-time access to a LHWP vehicle (Figure 6-4). Those Supervisors whohad partial access to a vehicle had it for an average of fourteen days. Only three percent ofSupervisors in the Punjab and ICT had no access to a vehicle and did not use publictransport. 42 Nationally the best vehicle access is in NWFP & FATA where seventy-twopercent of Supervisors have had full time access in the month prior to the survey. Thesituation is worst in Balochistan. 43In the month prior to the survey less than a third of Lady Health Supervisors in Punjaband ICT had received any POL allowance at all. 44 In addition the POL allowance in Punjaband ICT is still being budgeted for in cash rather than litres of fuel. This means the allowanceis vulnerable to rising fuel costs. The POL allowance needs to be adjusted to enable the LadyHealth Supervisor to visit all of her LHWs once a month with extra being provided foradditional responsibilities e.g. Immunisation days or transporting of supplies.40 See Chapter 3 on Levels of Performance.41 See Appendix 12 on Transportation for Supervisors and also the Quantitative Survey Report.42 ‘Public Transport’ includes privately owned transport.43 Due to the shortage of vehicles, Programme policy in recent years has been to provide travel allowance to urbanSupervisors and to allocate the vehicles to Supervisors working in the rural areas. Unfortunately travel allowance is not aperfect substitute for vehicle access, as we found in Chapter 3. Forty percent of LHSs- nationally and sixty-five percentfrom Punjab and ICT, used public transport in the past month.44 Nation-wide, around a quarter of the LHSs who had not worked in the week preceding the survey reported reasons relatedto vehicles, drivers or POL.32

SUPERVISION OF LADY HEALTH WORKERS AND THEIR SUPERVISORSFigure 6-4 Percentage of LHSs with Full or Partial Access to a Vehicle in the Past Month% of supervisors with full or partial access tovehicles in past month100806040200Punjab & ICTSindhNWFP &FATABalochistanAJK & NAsPartial access 31 30 6 5 32Full time access 36 27 72 41 28KEY POINTS• Supervisors in Punjab and ICT manage, on average, twenty-eight LHWs - similar to thenational average. Five percent of LHWs in Punjab and ICT do not currently have aSupervisor.• Of those who had supervisors, ninety-three percent of LHWs in Punjab and ICT hadreceived at least one visit in the past month and essentially all LHWs in Punjab and ICThad attended a monthly meeting at the health facility in the past two months. These aregood results• Supervisors in Punjab and ICT reported working on average twenty-three days in the pastmonth with most of their time spent in field supervision. However insufficient access tovehicles and lack of sufficient POL allowance is hindering good supervision. Only sixtysevenpercent of LHSs in Punjab and ICT reported having full-time or partial access to aLHWP vehicle in the month preceding the survey. LHSs who did not have vehicles diduse public transport but this is not a perfect substitute for vehicle access.• Lady Health Supervisors in Punjab and ICT are not getting as much opportunity to meetwith their supervisors as LHSs across the country. Only sixty-four percent had had such ameeting in the past month though this rises to eighty-six percent if we look at the past twomonths. These meetings should be an opportunity to provide the LHS with the supportneeded to deal with the poor performing LHWs and to provide better on-the-job coaching.33

Chapter 7PAY AND PROVISIONS- MEDICALSUPPLIES AND EQUIPMENTIN THIS CHAPTER:• Performance of the Pay System• Supply of Medicines and Equipment• Improving Distribution and Supply• Key Points

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTPERFORMANCE OF THE PAY SYSTEMLHW salaries are supposed to be paid monthly, directly into the LHW’s own bank account.At the time of the survey the salary payments system was not working well in both thePunjab/ICT and Sindh (Figure 7-1). In Punjab and ICT only thirty-five percent of LHWs hadreceived their pay in the past two months and forty-two percent had not been paid in overthree months. The distribution is essentially the same for Supervisors. In addition, seventeenpercent of LHWs in Punjab and ICT had received less money than expected when they lastreceived their salary i.e. less than Rs1440 for the month. The banks’ practice of deducting ahandling charge is the main reason for this. 45Figure 7-1 Percentage of LHWs’ Paid within the Past Two Months% LHWs paid within past two months10090807060504030201008981744935Punjab & ICT Sindh NWFP & FATA Balochistan AJK & NAsSUPPLY OF MEDICINES AND EQUIPMENTMedicinesThe overall picture on the supply of medicines for the LHWs kit is poor. LHWs throughoutthe country are seriously under-supplied with medicines and contraceptives needed toperform their role. In the Punjab and ICT, over half of the LHWs did not have eye ointment,Oral Rehydration Salts, vitamin B, antiseptic lotion, Benzyl Benzoate or bandages, in stock atthe time of the survey. Over a third did not have condoms and oral contraceptive pills or ironand folic acid tablets (Table 7-1). In most cases these items had been out of stock for the pastquarter. 46 Expired stock is not a big problem (Table 7-1). If the LHW has the item in stock itappears to be dispensed with a reasonable frequency. 47Staff members at the LHWs’ health facilities were also interviewed about theProgramme’s supply situation, since they distribute the supplies to LHWs. Basic Health Unitswere more likely to report supply problems than Rural Health Centres 48 . Nation-wide thenon-distribution of medicines by the health facility to the LHWs was usually attributed to the45 See Quantitative Survey Report.46 See Appendix 13: Supplies of Medicines and Equipment.47 See Quantitative Survey Report.48 See Quantitative Survey Report.36

PAY AND PROVISIONS- MEDICAL SUPPLIES AND EQUIPMENTsupplies not being available at the DPIU- eighty-one percent of respondents gave this as anexplanation.Table 7-1 Lady Health Worker’s Stock of Medicines- Punjab and ICTItemStock units% LHWs-out ofstock at time ofsurvey% of those LHWs,who were out ofstock, who hadn’thad the item formore than 3 monthsIf they hadstock: %LHW withexpired stockParacetamol tablets (500mg) Strip pack 32 16 3Paracetamol syrup Bottle 80 35 8Chloroquine tablets (250mg) Strip pack 24 51 1Chloroquine syrup Bottle 83 83 38Mebendazole tablets (100mg) Strip pack 30 58 2Piperazine syrup Bottle 33 47 2Oral Rehydration Salts Packet 97 99 34Eye Ointment Tube 90 86 0Cotrimoxazole syrup Bottle 55 31 9Vitamin B complex syrup Bottle 63 78 9Iron & Folic acid tablets (Fefan) Strip pack 37 85 N/A*Antiseptic lotion Bottle 61 42 3Benzyl benzoate Bottle 63 54 13Bandages (cotton) Pack 87 94 N/ACondoms Piece 37 69 N/AOral contraceptive pills Cycle 37 84 1*N/A if the number of LHWs with item in stock is too small to provide reliable estimatesEquipmentNationally most LHWs had the necessary items of equipment, charts and administrativematerials. 49 However there are shortages, and the Programme needs to both furnish theLHW’s kit when she begins her job and ensure that items are replaced or kept up-to-datethroughout her service.Figure 7-2 Percentage of LHWs without Manuals and without Weighing Scales% of LHWs without manual/weighing scale403530252015105097131215Punjab & ICT Sindh NWFP &FATA43413 1315Balochistan AJK & NAsManualWeighing Scale49 See Appendix 13: Supplies of Medicines and Equipment.37

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTIn Punjab and ICT, nine percent of the LHWs did not have a training manual (Figure7-2). The training manual is an ongoing reference source for the LHW and should beavailable and up-to-date. Seven percent of Punjabi and ICT Lady Health Workers do not haveweighing scales (Figure 7-2). This number rises to twenty-four percent if we consider thosewho don’t have both weighing scales and growth monitoring cards. These are important toolsfor conducting growth monitoring.IMPROVING DISTRIBUTION AND SUPPLYSince 1999 the Programme has had a system of replenishment for LHW supplies. Thissystem is not working as efficiently as it should. While purchasing is based on an annualstock-take, the long lead time for awarding tenders, receiving supplies, and having themtested, means that either the purchasing and distribution process must be made a lot moreefficient or minimum stock levels need to be higher. The level of purchasing needs to bebetter aligned to actual usage rates and this related to budget requests. These problems are forthe FPIU to resolve with co-operation from the PPIU and DPIU.However part of the problem seems to be uneven supply. Recorded stock levels andverbal feedback from the Provinces support there being sufficient Mebendazole tablets andIron and Folic acid tables in the system and yet there is a shortage at the facility andcommunity level.The PPIU and the DPIUs need to address factors contributing to poor supply, whichare under their control. These can include:• Poor transportation arrangements both from Provincial level to District and from Districtto Health Facility.• Lack of simple mechanisms for transferring supplies from an over-stocked district to aDistrict lacking stock.• A lack of commitment to ensuring supply from the District to the Health Facility.KEY POINTS• Improving the pay and supply systems is the responsibility of the FPIU and PPIUs.• In Punjab and ICT only thirty-five percent of LHWs had received their pay in the pasttwo months and forty-two percent had not been paid in over three months. The results aresimilar for Supervisors. The pay system at the time of the survey was not working well.• Numerous medicines had not been available for over three months. Supplies are notarriving at the health facilities for distribution. This problem has a number of causesincluding distribution from Provincial stores and insufficient supplies being purchased bythe FPIU.• In Punjab and ICT, twenty-four percent of the LHWs did not have both weighing scalesand growth monitoring charts- important tools for conducting growth monitoring.• Medical supplies and equipment are essential in ensuring an effective community healthservice. The credibility of an LHW in her community is undermined if she is unable todistribute contraceptives and other medicines as required. We found that having a supplyof medicines, in particular, increases overall service provision. The LHWP needs tourgently address problems in the supply and distribution of medicines and equipment38

APPENDICES

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTAPPENDIX 1:THE QUANTITATIVE SURVEYFieldwork using quantitative surveys was conducted between October 2000 and April 2001.The survey was conducted across all provinces and federally administered areas.The objective of the quantitative survey was to provide a nationally representativepicture of the functioning of the LHWP. Interviews were conducted with Lady HealthWorkers, the households that they serve, the communities where they work, theirSupervisors, and the health facilities to which they are attached. This provides acomprehensive picture for the work carried out by the LHWs and of the functioning of theProgramme support services necessary to their work. Information was also collected on a setof control households, where the Programme does not operate, in order to assess the impactof the LHWs on the health status of the population they serve. Information was collectedfrom health facilities and from the communities in these control areas.The sampling of LHW and control areas was complex. 50 It provided a representativesample of LHWs and the households that they serve. Since an estimate of the impact of theProgramme is required, LHWs were included in the sample only if they had completed theirtask-based training by the end of 1997. This means that they had been working in thepopulation that they serve for a minimum of four years by the time of the survey, whichallows enough time for LHWs to have had some impact on health indicators.LHWs were selected by sampling the health facilities to which they were attached.Two LHWs were randomly selected from each facility. From each LHW’s register, eighthouseholds were selected for interview. Interviews were carried out with adult women in thehousehold, covering a wide range of health topics. Interviews were also carried out at theLHWs’ health facilities, with the Supervisors and with members of the community where theLHWs serve – men and women were interviewed separately in two groups.Table A. 1.1 Sample sizes for Final AnalysisUnitFinal sampleLHW areasControl areasLady Health Workers 501 ---Households 4,015 1,146Health facilities 252 79Communities 469 81Lady Health Supervisors 244 ---The Federal Bureau of Statistics (FBS) selected control areas from the nationalsample frame, which is held by the FBS. Sample sizes are shown in Table A.1.1.50 A more substantial description is provided in the Quantitative Survey Report and the Survey Sampling Design.40

APPENDICESAPPENDIX 2:DEMOGRAPHIC AND EDUCATIONAL CHARACTERISTICS OFLHWS AND THEIR SUPERVISORSTable A. 2.1 Demographic and Educational Characteristics of Lady Health WorkersCharacteristicsNationalSindh%Punjab& ICT%%NWFP& FATA%Balochistan%AJK& NAs%Age distribution (age groups)15-19 1 0 1 0 5 320-24 20 16 27 26 46 1325-29 41 42 39 37 31 4930-34 15 14 14 18 12 2135-39 10 12 8 13 6 740-44 11 14 9 4 0 645+ 2 2 2 3 1 2Total 51 100 100 100 100 100 100Mean Age now 29.6 30.7 28.6 29 25.5 29.0Mean Age when Recruited 24.5 24.5 23.4 23.6 22.1 23.6Marital status of the LHWsNever married 28 26 30 40 42 13Currently married 62 63 60 55 54 79Widow/divorced/separated 10 11 10 5 4 8Years LHW has resided in Village/ Mohalla0-2 5 7 3 2 5 23-4 2 1 3 1 5 25-20 35 39 25 38 30 43More than 20 5 6 6 3 1 2Since Birth 53 47 63 55 59 51Total 100 100 100 100 100 100Non resident 4 3.2 6.8 0.0 14.1 1.5Educational levelLess than 8 th class 2 1 3 1 2 18 th - 9 th class 38 43 30 28 31 47Matric (10 th - 11 th ) 50 52 43 57 45 45Intermediate 9 2 21 12 19 6Graduate 2 1 4 1 4 1Class certificate seen and confirmed 74 83 66 79 67 6151 Due to rounding issues some totals do not actually equal 100.41

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTTable A. 2.2 Demographic and Educational Characteristics of Lady Health SupervisorsCharacteristicsAge distributionNational%Punjab& ICT%Sindh%NWFP &FATA%Balochistan%AJK &NAs%20 – 24 years 27 16 33 20 59 3525 – 29 years 50 52 47 56 29 5530 – 34 years 16 23 10 16 12 635 – 39 years 4 4 8 1 0 540 years and above 4 5 2 7 0 0Total 100 100 100 100 100 100Mean age 28 29 27 28 25 27Mean age at recruitment 25 24 25 24 23 23EducationMatric 4 8 0 6 0 4Intermediate 41 38 28 69 50 49Graduate 39 40 44 25 37 42Post-graduate 15 14 28 0 13 5Total 100 100 100 100 100 100Marital statusNever married 46 44 50 46 64 31Currently married 52 54 50 50 33 69Widow/divorced/separated 2 2 0 4 3 0Total 100 100 100 100 100 10042

APPENDICESAPPENDIX 3: SERVICE DELIVERY OF LADY HEALTH WORKERS- BYPROVINCEService delivery by Lady Health Workers to four of their important target groups is shown inTable A.3.1 These are; households (as a unit); women who have had a birth in the previousfive years; married women aged 15-49; and children under three. The people surveyed weretaken from a sample drawn from the LHWs’ household register.LHWs provide a range of promotive and preventive services to these groups. Thetable 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 52• supply and refer women for family planning• motivate and educate women on family planning• promote and facilitate vaccination52 There does not appear to be a wide problem of LHWs acting as substitute midwives. Only four percent of LHWs attendbirths. While communities report that LHWs sometimes attend births with dais, only around six percent of communitiesreport that the LHW ever conducts births without the assistance of a dai or medical staff (and some of these LHWs maythemselves be dais.)43

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTTable A. 3.1 Lady Health Workers Preventive and Promotive Services by ProvinceMeasureSindhNationalAveragePunjab& ICTNWFP&FATABalochi-stanAJK&NAsHouseholds registered with the LHW:• % who report that the LHW has ever talked tothem about ways to improve the cleanliness ofdrinking water• % who report that the LHW has ever talked tothem about ways to improve hygiene and reducediarrhoeaWomen who had a birth since 1997 (reporting ontheir last birth):• % who report that the LHW gave them advice onwhich foods to eat while pregnant• % who report that the LHW came to see her andthe baby within 24 hours• % who report that the LHW came to see her andthe baby within 7 days• % LHWs who weighed the baby (of those whocame to see the baby within 7 days)*• % LHWs who gave advice on breastfeeding (ofthose who came to see the baby within 7 days)*• % who report that the LHW gave her advice onfamily planning within 3 months of the birthCurrently married women (aged 15-49):• % of current users of modern contraceptives whowere supplied by the LHW• % of current users of modern contraceptives whowere supplied or referred by the LHW• % of current users of pills and condoms who werelast supplied by the LHW• % of non-users of modern contraceptives whohave discussed family planning with the LHW• % of non-users of modern contraceptives whohave discussed family planning with the LHW inthe last 6 months• % of current users of modern contraceptives whowere not supplied or referred by the LHW whohave discussed family planning with her• % of current users of modern contraceptives whowere not supplied or referred by the LHW whohave discussed family planning with her in the last6 months45 42 48 49 35 5844 40 49 50 32 5645 45 45 45 40 5110 7 14 12 13 1938 37 36 44 26 5144 41 42 51 50 5783 83 82 90 71 8540 41 38 39 28 4520 17 19 26 35 2532 30 27 36 40 5344 40 39 59 59 6941 46 34 36 20 4326 31 18 19 5 3044 48 33 45 35 4827 32 16 25 15 38Children under age 3 years:• % whose mothers say that the LHW talked to her 67 70 63 68 50 72about vaccinating the child• % whose mothers say that the LHW encouraged 60 63 55 64 39 65her to take the child for vaccination at the agewhen it was necessary• % whose mothers say that the LHW gave her 41 38 44 51 28 54advice on feeding the child• % ever weighed by the LHW 27 26 26 37 15 44• % weighed by the LHW in the previous 3 months 11 9 10 16 5 23* Excludes those where LHW was present at birth.44

APPENDICESAPPENDIX 4:HEALTH WORKERSCREATING A MEASURE OF PERFORMANCE FOR LADYThe measure we have developed of LHW-performance consists of ten preventive servicesthat all LHWs are supposed to provide. These cover LHW activities in hygiene, healtheducation, vaccination promotion, family planning, pregnancy and birth, child nutrition andgrowth monitoring. 53The ten services included in the performance measure are:• Number of households who report that LHW talked about ways to improvecleanliness of water• Number of households who report that LHW talked about ways to improve hygiene• Number of women aged 15-49, who are non-users of modern contraceptives, whoreport that LHW discussed family planning• Number of women aged 15-49, who are users of modern contraceptives, who reportthat LHW supplied them or referred them to a health centre• Number of mothers who gave birth since 1997 who report that LHW gave advice onwhich foods best to eat during pregnancy• Number of mothers who gave birth since 1997 who report that LHW saw mother atbirth or within a week of birth• Number of children less than 3 years whose mothers report that LHW talked aboutvaccination• Number of children less than 3 years whose mothers report that LHW encouragedvaccination• Number of children less than 3 years whose mothers report that LHW gave advice onfeeding the child• Number of children less than 3 years whose mothers report that LHW weighed thechild within the last three monthsThese ten tasks have been used for assessing the Lady Health Worker’s performance.Some services are only relevant to particular groups. The LHWs performance was measuredon the basis of whether or not she was providing services to those people who should havebeen receiving them.53 Curative services are excluded from this measure, as they are carried out on demand, and hence are not comparable acrossLHWs.45

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTAPPENDIX 5:LEVELS OF PERFORMANCETable A.5.1 provides more detailed information on the difference between Poor Performersand High Performers on ten services provided by the LHW. 54 We can see from the table thatthe Poor Performers (the bottom twenty-five percent of LHWs scored an average ofseventeen percent, and the High Performers (the top twenty-five percent of LHWs) scoredand average of sixty-eight percent. It is quite easy to distinguish Poor Performers from HighPerformers.Table A. 5.1 Different Levels of Performance amongst Lady Health WorkersBelowMeasurePoorGoodAverageHighAverage summary performance score 17 35 48 68% of households who report that LHW talked about ways toimprove cleanliness of water% of households who report that LHW talked about ways toimprove hygiene% of women aged 15-49, who are non users of moderncontraceptives, who report that LHW discussed family planning% of women aged 15-49, who are users of modern contraceptives,who report that LHW supplied them or referred them to a healthcentre% of mothers who gave birth since 1997 who report that LHW gaveadvice on which foods best to eat during pregnancy% of mothers who gave birth since 1997 who report that LHW sawmother at birth or within a week of birth% of children less than 3 years whose mothers report that LHWtalked about vaccination% of children less than 3 years whose mothers report that LHWencouraged vaccination% of children less than 3 years whose mothers report that LHWgave advice on feeding the child% of children less than 3 years whose mothers report that LHWweighed the child within the last three months20 40 50 7120 37 49 7120 37 49 6113 32 28 6012 33 53 7513 24 42 6128 61 76 9322 52 70 8712 27 50 785 6 12 2554 For further information see the Quantitative Survey Report.46

APPENDICESAPPENDIX 6:COVERAGELADY HEALTH WORKER ACTIVITIES AND POPULATIONTable A. 6.1 Number of Households and Persons Registered by Lady Health WorkersActivityNationalSindh%Punjab& ICT%%NWFP& FATA%Balochi-stan%Number of households registeredUp to 50 1 0 0 0 6 551 – 100 14 1 26 21 61 26101 – 150 39 25 57 57 23 59151 – 200 38 58 17 22 10 10201 – 250 9 16 0 0 0 0AJK&NAs%Total 100 100 100 100 100 100Mean number of households registered withLHW145 169 121 127 93 113Number of persons registered with theLHWsUp to 500 2 0 1 0 14 9501 – 700 6 1 12 5 35 11701 – 900 22 13 35 28 25 35901 – 1100 50 56 44 56 18 381101 – 1300 14 18 8 11 8 6More than 1300 6 12 0 1 0 2Total 100 100 100 100 100 100Mean number of persons registered with LHW 980 1062 898 952 723 855Table A. 6.2 Number of Hours Lady Health Workers Worked Last Week by Type of ActivityActivityNationalSindh%Punjab& ICT%%NWFP& FATA%Balochi-stan%AJK&NAs%Total no. of hours LHW worked last weekLess than 15 43 33 70 21 67 3115 – 19 13 11 13 17 10 1720 – 24 14 17 4 20 7 1925 – 35 21 24 9 28 11 24More than 35 10 14 2 12 5 8Total 100 100 100 100 100 100Average no. of hours/ activityHousehold visits 12.8 14.5 7.8 15.0 8.4 12.9Seeing patients at health house 1.3 1.5 0.8 1.3 2.0 1.0Administrative work 3 3.4 2.2 2.7 2.3 3.9Working with village or women 5 0.6 0.2 0.6 0.7 0.5committeeOther activities 2.5 2.5 2.4 3.3 1.5 2.9Total 20.1 22.4 13.3 22.9 15.0 21.247

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTTable A. 6.3 Days Worked by Lady Health Workers During Last WeekMeasureNationalSindh%Punjab& ICT%%NWFP& FATA%Balochistan%AJK&NAs%Number of days, LHW worked last weekDid not work at all 8 3 17 4 23 91 – 3 days 10 8 12 12 17 134 – 5 days 20 20 25 7 26 246 – 7 days 62 70 46 77 35 55Total 100 100 100 100 100 100Mean number of days worked last week 5 5.4 4.4 5.4 3.9 4.9Reasons for not working for full week 55Taking leave 22 18 24 28 14 25Sickness 17 12 23 12 26 9Travelled out of village/mohalla 8 7 9 10 6 7Work completed /not enough to do 7 8 4 0 13 3Others 48 55 41 50 40 56Total 100 100 100 100 100 100Table A. 6.4 Number of Household Visits Made and Number of Clients Seen during the PastWeek as Reported by the ClientMeasureNational%Punjab& ICT%Sindh%NWFP& FATA%Balochistan%AJK&NAs%Number of household visitsUp to 10 household visits 23 14 43 13 55 3311 – 20 17 13 26 20 21 1821 – 30 27 31 22 33 14 1931 – 40 18 22 8 21 7 1941 – 50 10 13 2 9 2 10More than 50 household visits 5 9 0 4 1 0Total 100 100 100 100 100 100Mean number of household visits made lastweek25 30 15 27 14 21Number of clients seen last weekUp to 10 clients 36 30 50 34 50 4011 – 25 41 44 40 32 34 4326 – 50 19 22 7 31 7 1551 – 75 2 2 0 1 2 2More than 75 clients 3 3 3 1 7 1Total 100 100 100 100 100 100Mean number of clients seenlast week20 22 15 21 19 1655 Full week means six days or more.48

APPENDICESAPPENDIX 7:THE KNOWLEDGE TESTDuring their interviews LHWs and LHSs were asked a number of questions to test theirknowledge in areas important in the LHWs service delivery. The questions covered a rangeof preventive and curative health care issues, hygiene and nutrition. They were also presentedwith a number of hypothetical case histories where they were asked to identify the problemand 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 answeredcorrectly. It is possible to score fifty-five points, twenty-eight for the general knowledgesection (Table A.7.1) and twenty-seven points (Table A.7.2) for the case studies. The score ispresented as a percentage of the highest possible score-i.e. fifty-five.The scoring attempts to identify LHWs with sufficient, general knowledge as well asto identify those LHWs with a depth of knowledge. For example, for questions with multiplepossible responses one point was given if a LHW was able to provide one correct responseand another point if she was able to provide three or more correct responses. The scoringwas as follows:49

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTTable A. 7.1 Scoring for General Knowledge section of the Knowledge TestQuestion Answer PointsContraindications for Oral Contraceptive PillContraindications for IUDAdvice about breast feeding to mother of newbornHow soon after birth should a mother startbreast-feeding her baby?One correct answerThree or more correct answersOne correct answerThree or more correct answersOne correct answerThree or more correct answersOne point if response is less than 4 hours afterbirth.1111111Should the mother feed to her baby thecolostrum?One point for ‘yes’ 1At what age should a mother begin tointroduce semi-solid foods into her baby’s diet?Can you name the vaccine and dose for:BCG?DPT?Polio?Measles?Can you name the correct age for doses of:BCG?DPT?Polio?Measles?How would you advise a mother of a child withdiarrhoea and mild dehydration if you did nothave ORS?One point for 4 to 6 months, or 4, 5 or 6months.One point for each correct answerOne point for each correct answerOne point for any one correct answerOne point for three or more correct answers11111111111What advice if child will not take ORS? One point for any one correct answer 1What advice to prevent diarrhoea?One point for any one correct answerOne point for three or more correct answers11How is malaria caught? One point for correct answer 1What treatment and advice for a two-year oldchild with symptoms of malaria?Name correct dose of Chloroquine for a childreferred to health facilityOne point if Chloroquine givenOne point if Paracetamol given or advice toreduce child’s temperatureOne point for ‘refer to health facilityimmediately- or if no improvement’One point for correct dose (1 teaspoon- onetime)1111How is HIV/AIDS transmitted? One point for any one correct answer 1Total possible points for GeneralKnowledge Section2850

APPENDICESTable A. 7.2 Scoring for Case-based Section of the Knowledge TestQuestion Answer PointsGrowth MonitoringCase 1:How much did the child weigh at four months? One point for 4.1 to 4.7 kilograms 1According to the card, what is the child’s One point for ‘normal to severely 1nutritional status now?malnourished’What does the card show about the child’s One point for stating that the child was gaining 1growth over the last four months?weight/ growing adequatelyWould this child need to be referred to a healthfacility?One point for ‘No’ 1Case 2:How much did the child weigh at four months? One point for 3.7 to 4.2 kilograms 1According to the card, what is the child’snutritional status now?What does the card show about the child’sgrowth over the last four months?What extra information would you request ifany?Would this child need to be referred to a healthfacility?One point for severely malnourished 1One point for stating that the child was failing 1to gain weightOne point if requested information about eating 1and feeding practicesOne point if requested information about recent 1illnessesOne point for ‘Yes’ 1DiarrhoeaCase 1:What is the degree of dehydration of the child? One point for mild to moderate dehydration 1What treatment and advice would you give? One point for rehydration (ORS or SSS) orbreast-feed more often.1One point if they advise to bring the child backfor reassessment soon or to seek help if thechild does not improve.1Case 2:What is the degree of dehydration of the child? One point for severe dehydration 1What treatment and advice would you give? One point for rehydration (ORS or SSS) or to 1breastfeed more oftenOne point for referral to the health centre 1Respiratory InfectionsCase 1:Does the child have a simple cough or cold,simple pneumonia or severe pneumonia?One point for severe pneumonia 1Would this child need to be referred to a health One point for ‘yes’ 1facility?What treatment and/or advice would you give? One point for Cotrimoxazole/antibiotics 151

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTQuestion Answer PointsCase 2:Does the child have a simple cough or cold, One point for simple pneumonia 1simple pneumonia or severe pneumonia?What treatment and/or advice would you give? One point for Cotrimoxazole/ antibiotics 1One point for giving fluids/ continuingbreastfeeding1PregnancyCase 1:What is the woman’s problem? One point for ‘anaemia’ 1What kind of examination is required and what One point for ‘examine conjunctiva’ or ‘ask1extra information would you request?about eating habits or recent illnesses’What treatment and advice would you give? One point for ‘Fefan’ or ‘eating more iron- rich1foods’Case 2:What treatment or advice would you give? One point for referral to health centre 1Would this referral be urgent? One point for ‘yes’ 1Total possible points for Case-BasedSection2752

APPENDICESAPPENDIX 8:THE KNOWLEDGE TEST RESULTSThe results for Lady Health Workers and their Supervisors, both nation-wide and for Punjab& ICT are presented below. These include the results for the general knowledge (FigureA.8.1) and the case based results (Figure A.8.2)Table A. 8.1 The Knowledge Test-General Knowledge Section. Percentage of CorrectAnswers given by LHWs and Supervisors, Nationally and in Punjab & ICTMeasure LHWs SupervisorsContraindications for the contraceptive pill:Total %Punjab &ICT %Total %Punjab &ICT %% giving at least one correct answer 93 94 100 100% giving 3 or more correct answers 50 53 88 91Contraindications for the IUD:% giving at least one correct answer 76 80 98 100% giving 3 or more correct answers 5 5 36 31Breastfeeding and nutrition:% giving at least one correct response about breast 99 99 100 100feeding% giving three or more correct responses about breast 65 61 67 58feeding% stating that mothers should start breastfeeding within 98 98 100 84four hours of birth% stating that mothers should feed baby the colostrum 96 96 100 100% stating that weaning foods should be introduced at theage of 4-6 months88 83 98 97EPI vaccination schedule:% who could name all four vaccines (BCG, DPT, Polio,Measles)% identifying all four vaccines and giving correct numberof doses% identifying all four vaccines and giving the number ofdoses and the correct ages for each dose94 97 98 10073 77 83 9043 48 59 63Diarrhoea:% giving at least one correct answer to mother of childwith diarrhoea and mild dehydration, if lacking packets ofORS% giving three or more correct answers to mother ofchild with diarrhoea and mild dehydration, if lackingpackets of ORS% giving at least one correct answer to mother of a childthat will not take ORS% giving three correct answers to mother of child thatwill not take ORS% able to give at least one correct response on how toprevent diarrhoea% able to give three or more correct responses on howto prevent diarrhoea100 100 100 10058 55 81 8285 87 100 10020 23 38 3496 97 100 10053 52 78 8253

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTMeasure LHWs SupervisorsTotal % Punjab &ICT %Total % Punjab &ICT %Malaria:HIV:% giving correct answer on how malaria is caught 92 90 97 98% saying they would give Chloroquine 56 60 61 56% saying they would refer to a health facility 80 78 88 95% giving correct dose of Chloroquine 6 7 10 10% giving at least one correct response on how HIV istransmitted% giving three or more correct responses on how HIV istransmitted93 96 100 10020 17 70 70Table A. 8.2. The Knowledge Test-Case Based Questions. Percentage of Correct Answersgiven by LHWs and Supervisors, Nationally and in Punjab & ICTMeasure LHWs SupervisorsGrowth Monitoring CardCase 1-Normal to Moderate Malnutrition:Total %Punjab &ICT %Total %Punjab &ICT %% giving correct weight of child 39 42 75 84% saying that the child is normal or moderately 68 73 64 62malnourished% stating that the child is growing adequately 68 67 76 73% correctly stating that referral is not necessary 78 86 86 97Case 2-Severely Malnourished:% giving correct weight of child 68 75 79 87% saying that the child is severely malnourished 40 46 93 99% stating that the child is failing to gain weight 30 24 50 42% correctly stating that referral is necessary 68 75 75 75% requesting information about eating and feeding 81 82 90 95practices% requesting information about recent illnesses 62 68 73 74% requesting information about eating and feedingpractices and recent illnesses56 60 69 72Diarrhoea/Dehydration ManagementCase 1-Mild to Moderate Dehydration:% stating that the child is mild to moderately dehydrated 75 78 88 97% stating that the child should be rehydrated (ORS or 84 82 83 75SSS)% stating that the child should be breast fed more often 77 79 84 90% stating that the child should be rehydrated (ORS or 94 95 98 97SSS) or breast fed more often% stating that the child should be brought back soon for 1 0 8 8reassessment% stating that the parents should seek help soon if the 9 6 15 8child does not improve% correctly stating that referral is not necessary 38 34 53 5554

APPENDICESCase 2-Severe Dehydration:Measure LHWs SupervisorsTotal % Punjab &ICT %Total % Punjab &ICT %% stating that the child is severely dehydrated 65 64 63 70% stating that the child should be rehydrated (ORS or 86 83 76 69SSS) or breast fed more often% stating that the child should be rehydrated (ORS or 58 84 61 56SSS) or breast fed more often and referred to a healthcentre% stating that the child should be referred to a healthcentre84 55 84 87Respiratory InfectionsCase 1-Severe Pneumonia:% identifying severe/very severe pneumonia 71 77 68 64% stating that the child should be referred to a health 89 91 85 83centre% stating that the child should be given antibiotics 84 87 87 88% stating that the child should be given a single dose ofantibiotics and referred74 79 75 72Case 2-Simple Pneumonia:% identifying simple pneumonia 21 18 28 25% stating that they would give antibiotics 85 91 77 85% stating that the child should be given fluids or breast 42 36 51 56fed more often% stating that the child should be watched for danger 6 4 11 6signs% stating that they would give a full course of 62 77 50 60Cotrimoxazole (of all LHWs/Supervisors)% stating correct dose & duration of Cotrimoxazolecourse (of those who would give a full course)23 23 31 N/A*PregnancyCase 1-Anaemia:% identifying anaemia 93 95 91 96% stating that they would examine the patient’s 77 81 82 90conjunctiva/eye for anaemia% stating that they would examine the patient’s 16 15 19 28conjunctiva/eye for anaemia, ask about the patient’s dietand ask about recent illnesses% stating that they would give iron tablets (Fefan) 80 78 72 71% stating that they would advise the patient to eat ironcontaining78 82 87 95foods% stating that they would advise the patient to avoidheavy work and to rest15 12 18 17Case 2-Pre-eclampsia:% stating that they would advise the patient have herblood pressure measured% stating that they would refer to a health centre andthat the referral would be urgent* Number of LHSs in sample too small for reliable estimates.12 16 10 561 51 61 4755

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTAPPENDIX 9:HEALTH SUPERVISORSTRAINING OF LADY HEALTH WORKERS AND LADYLADY HEALTH WORKERS’ TRAINING REQUIREMENTSThe 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 shewas recruited.• Twelve months task based (in-service) training, comprising one week full-time permonth for 12 months at the health facility.In addition, training can be provided, though not on a universal and compulsory basis, via:• Additional specialist short courses that either offer a reinforcement to the basictraining course, or alternatively, provide training in new areas;• Training given in monthly health facility meetings;• Training by supervisor in one-to-one monthly supervisory meetings.LADY HEALTH SUPERVISORS TRAINING REQUIREMENTSThe minimum standards that are expected of the training system for LHW supervisors are asfollows:• Phase One: initial training, using the same curriculum as the LHW and taking 8 weeksor more to complete it.• Phase Two: four months task-based training with two weeks in the field and twoweeks at their training centre.• Phase Three: six months task-based training with three weeks in the field and oneweek at their training centre.In addition, training can be provided, though not on a universal and compulsory basis, via:• Additional specialist short courses that either offer a reinforcement to the basictraining course, or alternatively, provide training in new areas;• Training given in monthly DPIU meetings;• Training by supervisor in one-to-one monthly supervisory meetings.56

APPENDICESTable A. 9.1 Training Received by Lady Health WorkersCategoryNationalAveragePunjab& ICTSindhNWFP& FATABalochistanAJK&NAs% of LHWs with initial training 100 100 100 100 100 100Duration of initial training (% of LHWs)Less than three months 1 1 0 3 0 3Three months 94 99 89 84 100 90More than three months 5 0 11 13 0 7Total 100 100 100 100 100 100Mean months for initial training 3.1 3 3.1 3.4 3 3.2Proportion of LHWs attended part-timetraining (one week/month)94 93 98 96 75 94Mean months of part-time training attended 12.4 11 15.5 12 11 12Training was imparted by 56 : (% of LHWs)Medical doctor (male) 87 80 99 86 98 91Medical Doctor (female) 20 16 29 16 33 20Lady Health Visitor 70 85 35 84 61 75Dispenser 48 64 28 34 10 52Male medical health technician 20 23 11 40 2 13Female medical health technician 8 6 7 30 12 0Others 3 3 3 2 14 2Proportion of LHWs who received taskbased94 93 98 96 75 94training (one week/month)Mean months of task-based training 12.4 10.9 15.4 12.2 10.9 11.9Proportion of LHWs who received refreshertraining95 99 98 80 94 89Proportion of LHWs who received refreshertraining on:Growth monitoring 70 75 69 46 75 77HMIS 71 77 69 37 84 82Iodised salt 77 95 48 66 70 65Immunisation day 86 88 89 70 87 86DOTS (treating tuberculosis) 36 32 35 49 41 52On-job by supervisor 51 61 45 39 44 28Training at health facility 63 64 70 34 71 7056 Multiple responses expected.57

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTTable A. 9.2 Training Received by Lady Health SupervisorsCategoryNationalAveragePunjab& ICTSindhNWFP& FATABalochistanAJK&NAs% of supervisors have initial training 96 92 100 100 96 96Duration of initial training (% LHSs):Less than two months 1 0 0 0 8 2Two months 32 34 32 45 21 12Three months 48 53 40 45 59 50More than three months 19 13 29 10 12 36Total 100 100 100 100 100 100Mean duration of initial training (months) 3.5 2.9 4.4 2.9 3.0 4.5Training was imparted by: (% LHSs):Medical doctor (male) 94 100 100 68 93 91Medical Doctor (female) 59 10 93 48 82 66Field Programme Officer 16 25 16 0 9 15Lady Health Visitor 47 77 23 83 30 27Dispenser 5 8 0 0 0 18Male medical health technician 3 0 0 30 0 0Female medical health technician 9 21 0 21 3 3Others 20 17 5 35 27 40Proportion of supervisors received:All training (Initial and task-based) 76 83 84 75 18 64Initial and one of the task-based training 14 9 10 22 29 26periodsOnly initial training 7 0 6 4 52 6None 4 8 0 0 2 4Total 100 100 100 100 100 100Proportion of Supervisors who receivedrefresher training:83 87 99 48 70 76Proportion of supervisors receivedrefresher training on:Growth monitoring 51 52 63 18 49 47HMIS 61 68 63 33 54 64Iodised salt 46 73 31 26 33 14Immunisation day 72 77 94 44 46 52DOTS (treating tuberculosis) 22 21 30 15 17 19IUCD insertion training 37 34 50 15 36 45On-job by District Co-ordinator 51 57 56 25 41 4958

APPENDICESAPPENDIX 10: SUPERVISIONTable A. 10.1 Supervision of Lady Health WorkersCategoryNationalAveragePunjab& ICTSindhNWFP& FATABalochistanAJK&NAs% LHWs without Supervisors 7 5 13 2 24 2% of their LHWs Supervisors have visited in 83 93 76 85 70 64the past 30 days as reported by Supervisor% LHWs who have had a monthly meetingat the health facility within:Last 30 days 85 91 75 80 56 9131-60 days 8 7 9 14 15 4More than 60 days 5 1 13 3 20 3Never attended 2 1 3 3 9 2Total 100 100 100 100 100 100Table A. 10.2 Supervision of Lady Health SupervisorsCategoryNationalAveragePunjab& ICTSindhNWFP& FATABalochistanAJK&NAsLady Health Supervisors last meeting forsupervision with their supervisor:Last month 70 64 81 68 78 52Two months ago 17 22 7 15 12 36Three or more months ago 9 13 6 5 3 2Never had a meeting or nosupervisor4 1 5 12 7 9Total 100 100 100 100 100 10059

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTTable A. 10.3 Lady Health Supervisors Workloads and Working PatternsCategoryNationalAveragePunjab& ICTSindhNWFP& FATABalochistanAJK&NAsNumber of LHWs assigned for supervisionUp to 10 3 7 0 0 0 011 – 20 17 7 25 13 20 4421 – 30 49 50 44 57 52 4531 – 40 25 29 23 26 26 9More than 40 LHWs 6 7 9 4 2 2Total 100 100 100 100 100 100Average number of LHWs currently supervised 27 28 28 29 26 23to each supervisorAverage number of days worked last month 22 23 23 22 20 17Percentage of Supervisors who worked a full55 54 67 51 50 25month (of 24 days or more)Average number of health facilities to which2.4 2.8 2.0 3.1 1.1 2.0Supervisors are attachedAverage number of health facilities visited lastmonth2.3 2.7 1.9 2.9 1.6 1.6Mean number of hours LHS worked last weekField supervision 16.5 19.6 14.9 14.7 11.1 13.7Individual meetings 1.4 1.0 1.2 1.7 1.9 3.5Monthly meetings at FLCF 2.1 2.5 1.9 1.4 0.8 2.9Administrative work 4.0 4.4 5.0 2.1 1.9 3.4Other activities 2.9 3.1 2.0 2.5 2.8 5.5Total 26.9 30.6 25.0 22.4 18.5 29.060

APPENDICESAPPENDIX 11: WORK PLANNING AND REPORTINGWork planning is an important self-management tool for LHWs. The LHW reports contributeto the Programme’s management information system. For Punjab and ICT LHWs eightyeightpercent could produce last month’s report and eighty-two percent were able to showtheir current work plan (Table A.11.1).Table A. 11.1 Lady Health Worker Work Planning and ReportingCategoryLHWs who said they had developed a work planfor current monthLHWs who could show the interviewer the workplanLHWs who said they had produced a report forprevious monthLHWs who could show the interviewer thereportWork planning should also be an important self-management tool for LHWsupervisors. Her reports can contribute to decision making and planning at the District level.For Punjab and ICT fifty-five percent could produce last month’s report and eighty-sixpercent were able to show their current work plan (Table A.11.2).NationalAveragePunjab& ICTSindh NWFP& FATABalochistanAJK&NAs71 86 42 81 43 5667 82 39 78 38 5598 100 95 96 94 9884 88 71 92 80 91Table A. 11.2 Lady Health Supervisor Work Planning and ReportingCategoryNationalAveragePunjab& ICTSindh NWFP& FATABalochistanAJK&NAsLHSs who said they had developed a work plan 84 87 87 94 60 72for current monthLHSs who could show the interviewer the work 74 86 63 71 49 72planLHSs who said they had produced a report for 87 93 82 95 56 91previous monthLHSs who could show the interviewer the report 53 55 59 29 54 5661

LADY HEALTH WORKER EVALUATION – PUNJAB AND ICT SURVEY REPORTAPPENDIX 12: TRANSPORTATION FOR SUPERVISORSTable A. 12.1 Transportation for SupervisorsCategorySupervisor’s usual access to a programmevehicleNationalAveragePunjab& ICTSindhNWFP& FATABalochistanAJK&NAsUsually or always available 64 68 62 81 30 58Sometimes available 11 8 9 11 31 16Never 25 25 30 9 39 26Total 100 100 100 100 100 100Use of programme vehicle and publictransport in month preceding the surveyFull time vehicle 38 36 27 72 41 28Part time vehicle and public transport 15 25.5 9 6 5 6Part time vehicle and no public transport 11 5.5 21 0 0 26No vehicle, public transport only 27 30 32 21 34 4No vehicle, no public transport 9 3 11 2 21 36Total 100 100 100 100 100 100Percent of LHS having a monthly POL71 69 70 90 51 66budget- % of LHS have POL budget in set amount 83 88 96 64 30 85of cash- % of LHS have POL budgeted in litres 17 12 4 36 70 15Total 100 100 100 100 100 100% receiving POL allowance in previousmonth% of the LHSs who used public transportduring last month35 28 29 53 70 3848 65 42 34 46 2162

APPENDICESAPPENDIX 13: SUPPLIES OF MEDICINES AND EQUIPMENTTable A. 13.1 Lady Health Worker Stock of Medicines- Nation-wideItemStock units% LHWs-out ofstock at time ofsurvey%of LHWs –with item out ofstock for morethan 3 monthsIf they hadstock: % LHWwith expiredstockParacetamol tablets (500mg) Strip pack 43 9 2Paracetamol syrup Bottle 78 30 11Chloroquine tablets (250mg) Strip pack 33 10 3Chloroquine syrup Bottle 75 36 22Mebendazole tablets (100mg) Strip pack 44 20 2Piperazine syrup Bottle 41 15 4Oral Rehydration Salts Packet 98 95 N/A*Eye Ointment Tube 84 51 2Cotrimoxazole syrup Bottle 57 20 7Vitamin B complex syrup Bottle 66 30 10Iron & Folic acid tablets (Fefan) Strip pack 37 16 N/AAntiseptic lotion Bottle 73 50 6Benzyl benzoate Bottle 58 27 9Bandages (cotton) Pack 82 70 N/ACondoms Piece 45 22 N/AOral contraceptive pills Cycle 45 11 5*Number of LHWs with Oral Rehydration Salts in stock was too small to provide reliable estimates.Table A. 13.2 Percentage of Lady Health Workers with Functional Equipment andAdministrative MaterialsItemPercentage of LHWs who have ItemNationally Punjab& ICTSindh NWFP& FATABalochistanAJK&NAsWeighing scale 91 93 88 96 66 85Thermometer 47 49 39 60 29 57Torch 11 2 19 32 15 22Scissors 75 77 75 76 54 74Household register 95 94 97 97 98 96Diary 86 91 78 95 86 75Manual 89 91 87 85 87 87Blank growth monitoring cards 74 82 54 83 59 71ARI case management charts (all 3) 91 93 88 90 75 91Diarrhoea case management chart 87 86 82 96 77 94Blank referral slips 77 83 62 96 55 6363