Increasing Contraceptive Use in Rural Pakistan: An Evaluation of the Lady Health Worker Programme

Published in Health Policy and Planning, this 7-page report presents findings from the first national evaluation of Pakistan's Lady Health Worker Programme (LHWP) Programme, a government effort to increase access to contraceptive services (particularly in rural areas). Authors Megan Douthwaite and Patrick Ward note that, while past efforts to promote family planning (FP) in Pakistan have been disappointing, contraceptive use has more than doubled since the LHWP's inception, rising from 11.9% in 1990-91 (National Institute of Statistics and IRD/Macro International 1992) to 27.6% in 2000-01. This resource describes the underpinnings of the LHWP, explores the context in which it was implemented, and provides data that indicates its impact.

Initiated under the Ministry of Health, the LHWP aimed at integrating FP into the doorstep provision of primary health care. Lady Health Workers (LHWs), who have a minimum of 8 years of education and are residents of the community they serve, undergo 15 months of training. They then serve approximately 1000 individuals, delivering a range of services door-to-door related to maternal and child health, including immunisation promotion, growth monitoring, FP, and health education. They treat minor ailments and injuries, and are trained to identify and refer more serious cases. Their FP responsibilities include motivating women to practice FP, providing pills and condoms, and referring for injections, intrauterine device (IUD) insertion and care, and sterilisation.

In this paper, data are analysed from a random sample survey of 4277 women living in households served by the LHWP and those living in control areas. (This evaluation was conducted 6 years after the LHWP began; no baseline data were collected at the
start.) In the served population, interviews were conducted with LHWs, the households they serve, groups of men and women in the communities where they work, the LHWs' supervisors, and key staff at the government health facilities to which the LHWs are attached. In control areas, information was collected from households, health facilities, and the community. Logistic regression analysis was performed to determine the effect of the LHWP on the uptake of modern reversible contraceptive methods, controlling for independent variables (various household and individual characteristics).

The data provide strong evidence that the LHWP has succeeded in increasing modern contraceptive use among rural women: Women served by LHWs are significantly more likely to use a modern reversible method than women in communities not served by the LHWP. For instance, within the cohort of women who were married and aged 15-40 in 1993 indicate a greater increase in ever-use of modern methods in the served population (from 9.3% to 40.3%) than in the control (from 8.7% to 27.5%). (To view a summary of additional impact data from this evaluation, click here). "These data suggest that the higher level of contraceptive use seen in rural LHW areas has occurred after the introduction of the LHWs, and is consistent with the hypothesis that LHWs have played a role in increasing contraceptive use in the
population that they serve....The net effect of the LHWP on the use of reversible modern methods is substantial and significant (OR = 1.50, 95% CI = 1.04-2.16, p = 0.031)."

In the report's Conclusion, the authors explore some strategic reasons behind this success: "While some commentators have observed that the LHWP may help to maintain, rather than challenge, social barriers that restrict women's mobility (Khan 1999), research on a similar, older programme in Bangladesh demonstrates that workers can act as important agents of change (Simmons et al. 1988, 1992; Mita and Simmons 1995). Studies in Bangladesh have shown that female workers counteract patriarchy and purdah and offer women a choice (Simmons et al. 1988), where otherwise they would have none. In Pakistan, where women's mobility is severely limited and female modesty highly valued, the provision of doorstep services through community-based female workers appears to be one model of service delivery that will help to achieve universal access to family planning by 2010."

Click here to access a related peer-reviewed summary on the Health e Communication website, and to participate in peer review.