Pakistan’s army of “Lady Health Workers” – some 90,000 strong – was never meant to diagnose and treat serious illnesses. Instead, these female community health workers (in Pakistan, men cannot visit families) were expected to teach good hygiene and nutrition, provide family planning advice, monitor pregnant women, weigh and vaccinate babies and treat minor ailments.
Yet a new study shows that these same women could hold the key to treating pneumonia – the world’s leading killer of young children.
The study, published by The Lancet medical journal and conducted by Save the Children US, funded by the US Agency for International Development and coordinated by the World Health Organization (WHO), found that children suffering from severe pneumonia were more likely to recover if treated at home by these women rather than in a health facility.
Roughly 1.4 million children younger than five die annually from pneumonia - 99 percent of them in the developing world, according to WHO. That is twice as many deaths as caused by malaria among under-fives, and more than those caused by HIV/AIDS, malaria and tuberculosis combined.
WHO guidelines have been modified to encourage the use of oral rather than injectable antibiotics, now that these have been identified as equally effective, but it still specifies that children with severe pneumonia should be immediately referred to a health facility and be treated there by health professionals.
Lady Health Workers are local women, who are literate and have completed eight years of school. But they receive just three months of full-time instruction, plus a year of training on the job.
In cases of severe pneumonia, they normally give a child one dose of a basic sulphonamide drug such as co-trimoxazole and tell the child’s family to go to the nearest clinic. This is where things start to go wrong, says Salim Sadruddin of Save the Children US. “Many families will not be able to make it there; they have no transport or no money. And if they do get there, service is slow or the provider is not there, so they will be unwilling to make the sacrifice to go again.”
A new approach
Sadruddin and his colleagues in Pakistan decided to see whether treatment could be given at home by the local Lady Health Worker. They ran a pilot project in Haripur district, in the south of Pakistan’s North West Frontier Province. Where the health workers identified severe pneumonia, with fever, rapid breathing and in-drawing of the lower chest, they were to give a full course of the WHO recommended antibiotic, liquid amoxicillin. “We wanted to see if they could do as well as conventional in-patient treatment. In fact, we found that they did better.”
The study followed 3,211 children, whose progress was checked six days after the start of treatment. Among those treated by their local health worker, only 9 percent failed to respond to treatment. In the control group, 18 percent failed to respond. The children visited at home started treatment sooner, and were sure to get the most suitable drug, while prescriptions in government and private clinics were far less consistent.
The Lady Health Workers taking part in the trial were carefully supervised. “These workers cannot just be left unsupervised after their training,” Sadruddin told IRIN. “They need ongoing support from their supervisors to attain their goals.”
The message was reinforced by the Elizabeth Mason, director of WHO’s Department for Newborn, Child and Adolescent Health.
“Supervision is absolutely critical, and it is one area that programmes have to ensure that they have well in place,” she told IRIN.
But she said WHO was extremely interested in the findings. “This is the kind of breakthrough research which is urgently needed. It is the first study of its kind and we will have to put it together with studies from other places. But I hope we may be able to review our guidelines to make treatment more accessible to poorer children and those living in remote communities, the ones who need it most.”
The programme also brought benefits to the women, elevating their status. In Haripur, when people saw that the women could treat seriously ill children and save their lives, their status rose dramatically, according to Sadruddin. By the end of the two-year trial, families were far more likely to make the Lady Health Worker their first port of call when their children were ill.
“When they started,” said Sadruddin, “the women themselves were not confident of their own abilities, and the community was also not confident. But when we went back, we found [so] much respect for the Lady Health Workers.”
* This story was amended on 14 November, correcting an error on the study results