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Limitations of Health Promotion Mechanisms: Pakistan

Author(s) Ayesha Aziz1.
Affiliation(s) Women's health, Rural Support Programmes Network, Islamabad, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Advocacy and Communication
Summary To improve the maternal and child health indicators the government of Pakistan initiated the Lady Health Workers Programme in 1994. This study aims to investigate the role of the programme mechanisms in promoting health and empowering people. The research was conducted in purposively selected villages from the districts Thatta, Rajanpur and Ghizer. Qualitative methods were used to gather data for the study. Our findings highlight that the limited understanding and implementation of community mobilization, health promotion and empowerment strategies, exclusion of the lower socio-economic strata and the absence of in depth comprehension of indigenous spaces for dialogue limit the LHW programme’s success.
Background Pakistan has been struggling to improve the maternal, newborn and child health of its population for the last two decades. The government has initiated several maternal and child health (MNCH) programmes to address issues related to availability, affordability and access to MNCH services. Reduction in the country’s maternal and child mortality is still far from meeting the targets of the millennium development goals according to which the maternal mortality rate (MMR) of 380 per 100,000 live births was to be reduced by three-quarters and the infant mortality rate (IMR) of 76 per 1000 live births was to be reduced by two-thirds by 2015. However, the current MMR in 2010 was 260 per 100,000 live births and the IMR was 59 per 1000 live births. The National Programme for Family Planning and Primary Healthcare is one of the largest government health programmes. It was initiated in 1994 with the mandate of overcoming the financial and mobility barriers related to access and ensuring continuous availability of primary healthcare services at the doorsteps of rural communities. The most recent evaluation of this programme, conducted by the Oxford Policy Management in 2009, has revealed that despite all efforts of the programme there has been limited success in behavior change for health promotion.
Objectives Health promotion is considered a process of enabling people to increase control over and to improve their health. It is related to empowering people by developing skills of local leadership, strengthening community actions, creating supportive environment, reorienting health services and building healthy public policies. The National Programme for Family Planning and Primary Healthcare is widely known as the Lady Health Workers Programme as its prime workforce consists of community based Lady Health Workers (LHWs). The LHWs are responsible for advocacy, health education and creating awareness for promoting community health. Their work includes counseling, provision of family planning services, antenatal care and referrals, immunization, basic curative care and supporting community mobilization. There are a total of 90,000 LHWs employed in the programme across the country. Each LHW serves 1000 people living in the 100-200 households around her own house that is called the ‘health house’. For health promotion the LHWs are responsible for mobilizing the community into groups, particularly those of women. Over the years, the LHWs have gained a lot of respect and influence in their communities and their contribution in ensuring availability of affordable primary healthcare has been valuable.
This study aims to investigate the role of the LHW programme mechanisms and the LHWs in promoting health and empowering people, particularly the women and poor. The study will also explore the indigenous mechanisms and spaces for dialogue that exist in every community and endeavor to distinguish the impact of indigenous communication mechanisms and spaces on maternal and child health promotion from the programmatic ones.
Methodology The primary research question for this study was ‘in what ways do LHW programme mechanisms and spaces empower or inhibit women, poor persons and marginalized groups, particularly with respect to maternal and child health issues? The following refined research questions were defined from the primary research question.
1. What are the mechanisms and spaces formed by the LHW programme for promotion of MNCH?
2. How are the selected communities stratified? (ethnic groups, economic classes, castes, education status, gender and age)
3. What are the marginalized groups in the selected communities?
4. Who is included and who is excluded from the LHW programme mechanisms and spaces? And why?
5. What are the mechanisms of inclusion and/or exclusion in the LHW programme mechanisms and spaces?
6. What is the role of LHWs in engaging and empowering the women and poor?
7. What indigenous mechanisms and spaces for dialogue exist in the selected communities?
8. What is the impact of the indigenous and LHW programme mechanisms and spaces on raising awareness about health issues, availability of health services and entitlements of people for MNCH services?
9. What is the impact of the indigenous and LHW programme mechanisms and spaces on women’s mobilization and local accountability processes?
10. What lessons can be learned with respect to accountability and governance in the LHW programme and the identification, training and selection of the LHWs? To take into account the cross country geo-cultural differences, this research was conducted in a purposively selected LHW covered villages from the districts Thatta (delta), Rajanpur (plain) and Ghizer (mountainous). A comprehensive document review of relevant documents of the LHW programme was done and a total of 9 key- informant interviews (KIIs) were conducted with three LHW programme personnel in each village/district to gather information on the planned and implemented mechanisms for maternal and child health promotion. The community’s perspectives on the role of programmatic mechanisms and LHWs in health promotion was investigated by conducting 10 participatory reflection and analysis (PRA) based group discussions (5 with women’s group and 5 with men’s group) in each of the three selected villages. Indepth interviews with selected women were also conducted to distinguish the impact of indigenous communication mechanisms and spaces from the programmatic ones.
Results • Community mobilization mechanisms are utilized only for awareness raising
In all our study sites, LHWs were found to visit households on specific dates during the immunization campaigns, though they have a mandate to raise awareness and change attitudes by the formation of a women’s group and health committee in their catchment area. In each site, LHWs were found to conduct occasional awareness raising sessions on antenatal care and contraception. Communities in Thatta and Rajanpur did not know of any women’s group or health committee. In Ghizer some women informed us about a women’s group created by the LHW 2 years ago, but such group activities were no longer a part of the LHW’s routine work as she had a high work burden and was not held accountable for mobilization efforts.
• People from lower socio-economic strata were excluded and their women bore the highest burden of MNCH issues.
In villages of Thatta and Rajanpur Districts the community was stratified with respect to lineage that formed their caste identity, while in Ghizer it was stratified on the basis of religious sects. The men and women from the lower socio-economic strata were excluded from the awareness sessions as the LHWs were either relatives or friends of the better-off women and tended to complete their field activities with them without making much effort to ensure representation and participation of all strata. Due to lack of access to information and resources the poorest women in each site withstood the highest burden of MNCH issues. They related horrid stories of multiple young age pregnancies, miscarriages and even infant deaths. The most vulnerable women were those belonging to the poorest castes that led semi-nomadic lives in search of livelihoods. They were not even counted as women eligible for primary healthcare and family planning advice in LHWs’ registered catchment area population.
• Indigenous spaces for dialogue can serve as entry points for behavior change
In Ghizer, the place for congregational worship was used by women from the same religious sect to discuss and promote contraceptive usage. In Thatta and Rajanpur Districts, the agricultural activities and household gatherings were used to exchange information on contraceptive usage, but due to deeply ingrained patriarchal practices of the society, very few women could use this information for behavior change.
Conclusion Our findings highlight the limited understanding and implementation of community mobilization, health promotion and empowerment strategies in the LHW programme. This has restricted the focus of LHWs’ community mobilization activities to awareness raising, while their potential for promoting organized and sustainable community based collective efforts for building local partnerships and ensuring accountability of healthcare services remains unharnessed.
Social stratification determines people’s access to resources, livelihood, ownership of agricultural land and socio-economic status, therefore equitable access to information and health can be ensured by monitoring inclusion of the lower socio-economic strata and the semi-nomadic population groups in the community mobilization efforts.
The indigenous spaces for dialogue among women in all communities included communal places for washing clothes, collecting water and performing agricultural activities and the household gatherings for celebrating events. These spaces contribute to the construction of cultural norms and practices in a society. Therefore, in-depth comprehension of the indigenous spaces will allow the LHWs and their programme to capitalize upon existing opportunities for dialogue and behavior change for health promotion and empowerment.

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