National Program for Family Planning and Primary Health Care in Pakistan, also known as the Lady Health Worker (LHW) program, consists of 100,000 locally resident female Community Health Workers (CHWs) who provide family planning, antenatal and child health care services with a coverage of about 50% - 60% of rural areas and urban slum populations [1] . LHWs form the first level of trained squad that provides Mother and Child Health services at primary care level. Females that fulfill the eligibility criteria of education of grade 8 level and residence in local community, were recruited and trained for 15 months as LHWs to serve as their particular communities. On average, one LHW generally serves around 100 - 150 households in her catchment area. The program also inducted “lady health supervisors” (LHSs) to monitor and supervise 20 - 25 LHWs on regular basis [2] [3] . Despite the functioning of the LHW program since 1994, the progress remained suboptimal as shown by the facts that Pakistan is 5^th most populous country of the world with 68% of its population aged under 30 years. Additionally, with a total fertility rate of 3.6, the country’s population is increasing much faster than that of its neighbouring countries in South Asia. The modern contraceptive prevalence rates are stagnant at around 25% during the last 5 years. Also, the unmet need for FP is high. About 17% of all married women want to avoid or postpone their pregnancies but are unable to do this because of inaccessibility to contraception methods [4] . In 2015, Bhutta et al. concluded that most evaluations of the LHW program and many informal reports identified several weak areas and opportunities for further enhancement of LHW skills [5] . The study encompasses the extent of challenges identified by the researchers that undermine the performance of LHW while working in rural communities, and attempts to combine the recommendations of the researchers for addressing the challenges using a structured approach.

The literature search included articles from 2000 to 2024. PubMed and Google Scholar were the main search engines utilized, using MESH terms Lady health Workers, Community Health Workers, low- and middle-income countries, Pakistan. Initial search result in 1380 articles on Google Scholar. The search was filtered by adding the key word Pakistan and low- and middle-income countries. Out of these, the non-relevant topics and studies were omitted and only the ones showing a link to the study title were included in the review. From the total articles searched, 56 were selected for writing this article.

For the LHW program to deliver results in Pakistan, a number of key issues have been identified by the researchers who have proposed various solutions and recommendations for more effective implementation of the program across the country. In 2013, Wazir et al., while doing a SWOT analysis of The National Program for Family Planning and Primary Healthcare in Pakistan, identified the weaknesses of the program including poor administration and incorporation at lower levels, issues in salaries disbursements, job insecurity, interrupted supplies of medicines and equipment , feeble referral systems, poor incorporation of digitalization in health system, weak supervision and connections with marginal health facilities and slow progress in meeting targets [6] . In a study by Aboubaker et al., in 2014, it was emphasized that effectual implementation of CHW program needs policy support, trainings, supervision and performance maintenance [7] . Haq et al., in their study conducted in 2008 concluded that apart from administrative issues, the rest of the concerns of LHWs are linked to interpersonal and communication skills. The study also revealed that a large number of health workers are not pleased with job due to apparent absence of professional growth career path [8] . Shaista Bahar et al., in a study of 2 union councils of District Nowshera, Khyber Pakhtunkhwa, concluded that LHWs faced behaviour issues of the community and security threats [9] . Jalal et al., in a study conducted in 2011 concluded that In Pakistan, there is a diverse range of issues in LHW program including deficiency of continual medical education and sustained motivation [10] . In 2023, Jafree et al., highlighted reasons of low efficiency of LHWs are insufficient training, unresponsiveness of centre, unproductive monitoring, sensitivities about safety and work–live balance, suspicion of medical services, perceptions about provider incompetence, lower health literacy and limitations by families for travelling [11] . Hafeez et al., while studying the LHW program in 2011 concluded that in spite of the noticeable strengths of the programme, there are some weaknesses that need to be addressed. Authors recommended more emphasis on equity, community participation and inter-sectoral coordination [12] . Hashim et al., in 2021, recommended modification in the work pattern of LHWs to follow the equality on the base of distance, hard to reach areas and fuel consumptions. Societal structure, family support and field work issues like harassment, unequal wages and responsibility, polio work from dawn to dusk, unequal resource distribution, over work load and work life balance are linked with LHW’s work performance [13] . Jabeen et al., in their study 2021, raised the issues that due to excessive workload, LHWs are unable to complete all domestic responsibilities and to spare time for their personal needs, families and social obligations resulting in domestic strives, health issues, negligence towards children and isolation from social life [14] . In 2010, Ariff et al., carried out training needs assessment among healthcare providers including LHWs in the public health sector of Pakistan, concluded a vigorous need to improve existing knowledge and skills through continuing medical education and relevant trainings [15] . In 2021 Bechange et al., emphasized that an important factor highlighted in interviews by LHWs was their non-clarity about tasks and what was anticipated from them [16] .

A number of interventions appear to be effective in improving the efficiency of LHWs in Pakistan. Haq et al., in their study in 2009 concluded that a sustained process should be established by primary health care programmes where opportunities should be provided to LHWs to update their knowledge, improve communication skills and bring trustworthiness to their identity as health educators [17] .

Aftab et al., in a study conducted in 2021 concluded that training supervisors to offer comprehensive and regular feedback in a supportive way can improve the quality of care provided by the LHWs [18] . Nisar et al., in a study conducted in 2016 concluded that in Pakistan, to progress the effectiveness of monthly meetings, it is necessary to enhance the communication skills of the LHWs [19] . Sohail et al., in their study in 2021 concluded that improvements in the syllabus of LHWs are required to make it well-matched with evolving health issues needs [20] . Shahmalak et al., in their study conducted in 2019 emphasized that trainings can have a positive effect regarding self-confidence and development of skills [21] . Afsar et al., in their study conducted in 2003 assumed on the basis of their findings that referral success and utilization of health care can be improved with an improved communication between LHW and client. This need trainings in communication skills and counselling as well as the technical capability of the LHW [22] . Memon et al., in their study in 2023 recommended that at the community level, training and capacity building of CHWs have the potential to counter damaging gender norms, mythologies and misapprehensions regarding family planning, sexual and reproductive health [23] . Din et al., in their study in 2022 concluded that LHWs’ skill of communication is directly associated with availing family planning services provided by them. Authors recommended periodic revision of the curriculum of LHWs’ training to encounter the varying needs of the clients [24] . Salam et al., in 2016 highlighted a strong potential for training and task-sharing to LHWs for providing inclusive antenatal care [25] . In a study by Shah et al., in 2020, it was concluded that in-service trainings and professional growth are vital contributors to maintain the competencies for delivery of quality services by community workers, particularly in low- and middle-income countries [26] . Schleiff et al., in 2021, recommended that training is an inclusive and active element of CHW programmes that needs to be well funded. Training should be ongoing iterative training including training of the community, supervisors and others within the health system to help these stakeholders understand, appreciate and make effective use of CHWs [27] .

Regarding violence against healthcare workers, Mukhtar et al., in 2024 emphasized that there is a need of joint effort by health communities, humanitarian & civil society organizations, media and health professionals to increase awareness at national and global level [28] . Gibson et al., in 2023 recommended that LHWs while traveling outside their communities may be accompanied by their husbands or police, as they may have confronted threat or been perceived poorly by outside communities [29] . Closser et al., in their study in 2023 emphasized that Universal health programmes, governments and influential funders can do ample more to protect CHWs from harassment and violence. There is a chance for implementing solutions that have been tried effectively in other areas, with the CHW support and community engagement [30] . Shaikh et al., in a study conducted in 2020 concluded that main motives of violence amongst LHWs and vaccinators were linked to the behaviour of clients. Authors emphasized that there is a need to review the strategy to address the concerns of public and to build national harmony on prevailing controversies connected to these services [31] .

Nkonki et al., in 2017 in their study emphasized that due to the significance of CHWs in attaining worldwide health coverage, it is to be likely that research on effectiveness and cost-effectiveness of CHWs will remain [32] . Research on CHW relationships with the health system and communities, should be done more analytically in order to recognize which factors have the most effect on CHW programme performance. Improved monitoring and additional research are necessary for improved supervision and recognizing what works better in a specific context [33] [34] . Astale et al.,2023 recommended that program managers should focus on how the added tasks can be integrated into the present responsibilities of CHWs [35] . Mumtaz et al., in a study conducted in 2013 recommended that when defining the LHWs’ catchment areas, careful attention should be given to their societal geography concerns [36] . Shahid et al., in a study conducted in 2022 highlights the necessity of robust supervision and monitoring of LHWs, equal development opportunities and providing transport to confirm regular visits [37] . Rabbani et al., in 2021 emphasized that social, topographical, and financial inequalities should be considered in while developing interventions [38] . Referral system by the LHWs must be strengthened and referrals by LHWs be given importance at First level health facility [39] . In a study by Lewin et al., in 2021 it was recommended that policy-makers and other stakeholders need to consider which systems are currently in place and how they might be modified and associated with local needs and systems. Community should be educated about allocated roles and tasks of LHWs and involved community in development of CHW programme Program [40] . A study conducted by Khan et al., in 2019 concluded that interventions apart from monetary incentives could be utilized to surge LHW engagement. Evolving context-specific strategies that blow into internal motivation could let programmes to improve engagement of CHWs [41] . Rahman et al., in 2019 suggest that technology can be a cost-effective approach to train and supervise health workers in resource constraint settings [42] . In a study conducted by Ballard et al., in 2017, authors have the view that using mobile phone-based technical guidance improves behavioural outcomes for patients and quality of care provided by CHW [43] .

In 2019, Rogers et al., in their study concluded that they need strong monitoring and supervision, a practicable workload and context-specified, appropriate salary to enhance effectiveness and cost-effectiveness [44] . A study by Rabbani et al., in 2014 emphasized that sufficient supportive supervision of CHWs has also been reported to be a vital aspect for safeguarding effectiveness of weak health systems [2] . Closser et al., in a study conducted in 2013 recommended first-class security strategies and chances for career growth and progress [45] . Oladeji et al., in 2024 emphasized that countries need to review their CHWs program design and develop empowering policy environment [46] . Raven et al., in 2022 recommended that local level initiatives are important in supporting CHWs, including support for income generation, flexible module-based training processes close to CHW homes, long term solutions focusing on community sensitisation, multi-sectoral action and continuing supportive supervision and flexible working lines that support CHWs to work life balance [47] . In a study by Majid et al., in 2021, authors emphasized that it is important for CHW programs to clearly recognize the importance of the impact of cultural standards and beliefs on CHW practice [48] . Jafree et al., in a study conducted in 2022 indicated four important aspects for support to expand mother and child health services by CHWs during pandemics including education and training, operational support, public acceptance and employee support and benefits [49] . Colvin et al., in 2021 shows the importance of giving local managers flexibility in developing and maintaining suitable incentives over time, the necessity to efficiently support CHWs in ways that are perspective to local conditions and more inclusive in approach will eventually result in greater CHW motivation [50] . Glenton et al., while studying the CHW programs of various countries in 2021 recommended that policy-makers should draw global guidance and evidence about the experiences, requirements and concerns of communities and health workers [51] . In 2021, Perry et al., emphasized that it is the time to involve political leadership, health managers and other stakeholders to visit model CHW programmes by inviting them to local and global seminars and conferences, where learning from these programmes is shared [52] . McCollum et al., in 2016 emphasized that care need to be taken by policymakers and implementers to focus on CHW programme features which can affect the equity of services [53] . In 2021, Afzal et al., in their study emphasized that the multisectoral scopes of CHW policy and program may be addressed in a better way through a national coordination mechanism of stakeholders with a strong national pledge [54] . The key recommendations of the various studies are summarized in Box 1 .

Box 1. Summary of key recommendations.

This paper explores the extent of issues and challenges faced by LHWs in Pakistan. Literature highlighted the importance of community selection, monitoring, monetary as well as non-financial incentives; trainings; availability of supervision, workload balance, monitoring; recognition, clarity on roles, resources and uninterrupted supply of logistics, support and embedment of LHWs in community and health system. Lack or poor quality of these aspects may lead to low performance of LHWs. There is a need to ratify the status and recognition of LHWs as a vital and esteemed part of the health workforce in health system of Pakistan. Efforts should be made at various levels to increase the utilization of this human resource for providing community-based health care services. The review may serve as an essential resource for program planners and decision-makers in improving the effectiveness and efficiency of LHW programs.