Health Care

The STRONG framework for supporting FLWs for immunization in Pakistan

December 14, 2023
5 min read

Female frontline workers – an indispensable asset in effort to immunize Pakistan

In recent years, Pakistan has made significant progress in eradicating polio, and female healthcare workers have played a pivotal role in this success. This model has been a proven success across the world –as shown in Exhibit A.
Exhibit A LHW models across healthcare system

Today, women make up 62 percent of the Polio frontline teams in Pakistan. These Polio teams successfully vaccinated approximately 43.5 million children in the December 2021 National Immunization Drive (NID).

In Pakistan, LHWs are responsible for about 1,000 people spanning 200 houses in their catchment area. Their duties include providing basic health services and family planning, referring patients to nearby clinics, organizing health committees for both men and women, and promoting the uptake of public health initiatives.Since the start of the program in 1997 until 2007, the indicators for Contraceptive Prevalence Rate, Fully Immunized Children and Skilled Birth Attendance have all increased while maternal mortality came down from 500 to 180, and infant mortality has come down from 105 to 49- see Exhibit B.

Exhibit B LHWs contribution to the system

More female vaccinators, more children vaccinated

Women are often the primary caregivers in households, and their role in creating awareness about vaccination has been critical. Female vaccinators and social mobilizers have proved to be an essential asset in improving attitudes towards polio vaccination and the perceptions of risks associated with the disease. They successfully reach out to women and children in communities, built their trust and confidence, and highlighted the importance of vaccination.

FFW shave also contributed to the increased effectiveness of health service delivery and vaccinations. In some communities where cultural norms prevent men from entering households, female community polio workers are in the frontlines, building community trust and reaching all children. These women are trained to deliver polio vaccines and other essential healthcare services to children and families. Female healthcare workers have been successful in building a bridge between healthcare providers and communities that may be hesitant to accept healthcare services.

Incorporating technology to empower female workers  

With the increased availability of smartphones and other digital devices, female healthcare workers in Pakistan are now using technology to improve their service delivery outcomes.

One example of technology's successful implementation is the introduction of digital mapping tools that help healthcare workers navigate remote areas and improve their accuracy in tracking vaccination coverage. Female healthcare workers walked area boundaries and team routines multiple times to improve map accuracy, even in difficult terrain. By using digital tools, healthcare workers could accurately locate missed areas or streets, which increased their effectiveness in reaching all children.

Furthermore, technology has enabled healthcare workers to participate in routine reviews. By using digital devices such as tablets and smartphones, healthcare workers were able to collect data in real-time, which allowed them to compile data and utilize it in a routine manner. This improved their individual skillset, reduced data errors and made processes more time efficient.

Moreover, female healthcare workers in Pakistan have overcome significant challenges to serve their communities. Many women face cultural and social barriers that restrict their mobility and limit their access to education and healthcare. These barriers often discourage women from pursuing careers in healthcare. However, female healthcare workers have broken these barriers and become a beacon of hope for many women in Pakistan. They have played an essential role in empowering women and creating opportunities for them to participate in the workforce.

Much needs to be done to support these frontline workers, as women at the intersection of eradicating a critical disease, and with limited access to resources and technology.

FLWs especially women face several issues in delivering their work. Some of these are human resource issues which include the lack of adequate resources from the state.  As many of these women are from low-income communities and often do not meet the minimum education requirement, there is a need for significant investment in upskilling. There's also an absence of a defined service structure for career growth and missing civil servant benefits like pensions and medical allowances. Managerial challenges encompass the shortage of qualified instructors for proper training, inefficient coordination between health care facilities and union councils, and the absence of a structured procurement system for accurate demand forecasting and supply distribution. Financially, the devolution of the LHW program was not complemented by adequate fiscal transfers, leading to significant salary payment delays due to fund release holdups.

Proposed solutions for these challenges must rest on three basic tenets and by focusing implementation of Impetus’s STRONG framework - see

They need to be heard.

It is crucial to introduce a formal complaint mechanism, promote a gender-sensitive work culture through specialized training programs, protect the right to refuse field responsibilities during pregnancy, and increase female leadership in town/UC level staff. These measures will empower female healthcare workers, promote gender equity, and enhance their well-being, which in turn will improve healthcare service delivery outcomes in Pakistan.

They need to feel protected.

To further improve the work environment for female healthcare workers in Pakistan, it is crucial to create and implement a comprehensive harassment policy to prevent all forms of harassment, discrimination, and violence against women. The policy should include clear guidelines on how to report incidents, an investigation process, and disciplinary actions for offenders. Moreover, it is vital to guarantee protection from all forms of violence against women, including physical, sexual, and emotional abuse. This can be achieved by implementing security measures in all field activities, and additional security measures in areas of high risk. Providing a safe and secure work environment is crucial to empower female healthcare workers to deliver healthcare services effectively and to promote gender equity in the healthcare sector.

They need to be guaranteed basic rights.

To further support female healthcare workers in Pakistan, it is important to allocate them with minimum wage and equal opportunities for growth to ensure fair compensation and professional advancement. Additionally, it is important to provide female healthcare workers with access to lunch and toilet breaks during campaign days to ensure their basic needs are met. Furthermore, female healthcare workers should have the right to a maternal leave with full pay to support their physical and mental well-being during pregnancy and post-childbirth. Lastly, female healthcare workers should be trained in social and technical skills to prepare them for equal participation in work, to promote their career advancement, and to build their confidence and capabilities in handling diverse work situations. Empowering female healthcare workers with these basic rights and resources is crucial to enhance their professional and personal lives and to promote gender equity in the healthcare sector in Pakistan.

Exhibit C STRONG framework to support FLWs