Pakistan has an extensive public primary health system, largely composed of female frontline health workers, namely Lady Health Workers (LHWs) who provide services in their communities, supervised and supported by Lady Health Supervisors (LHSs), and Lady Health Visitors (LHVs), who provide services at health facilities. Initiated in 1994, there were 110,000 LHWs in 2014, covering 50% to 60% of target households in the provinces. Hired and placed locally, the primary responsibilities of LHWs are to provide basic promotive, preventive, and curative services in their communities, including family planning methods and maternal and child health services. Each LHW is affiliated with a public health facility in, or near, her community, where she receives training, support, medical supplies, and pay (Zhu et al. 2014, Bhutta et al. 2013; Zaidi et al. 2013a).

Comparing households in areas served by LHWs to households in unserved areas in the same districts based on regression and propensity score matching, OPM (2009) finds that LHWs have significant and large positive effects on modern contraceptive use, neonatal checkups, and full immunization; significant, but modest, positive effects on child growth monitoring; and insignificant effects on skilled attendance at birth, breastfeeding, child diarrhea, or respiratory infection.<sup>46</sup> Using data from the rural household panel subsample of the PPHS and based on regression, Arif et al. (2014) find that greater LHW activity in villages, proxied by the percent of households in the village visited by such workers in the three months before the survey, has a significant positive effect on HAZ, WHZ, and WAZ.

Some studies have assessed the effects of interventions aimed at improving the performance of primary health workers in general and of LHWs in particular. Zaman, Ashraf, and Martines (2008) examine the effects of providing training and communication materials to LHVs for child feeding counseling to mothers. The intervention was randomized across a sample of health facilities in Lahore, Punjab. The study finds that the intervention raises the competencies of LHVs, and improves the knowledge and self-reported child feeding practices of mothers. The intervention has a significant positive effect on WAZ and WHZ of roughly 0.5 standard deviations and an insignificant effect on HAZ, measured six months after mothers first consulted trained LHVs. Omer et al. (2008) examine the effects of providing training and communication materials to LHWs for counseling women on the need to attend prenatal checkups, to reduce their workloads during pregnancy, and to feed colostrum to their newborn children. The intervention was randomly assigned across a sample of communities in Sindh. The study finds that the intervention has positive effects on all three outcomes, measured 10 months after LHWs started using the materials in communities.<sup>47</sup> Yousafzai et al. (2014) examine the effects of stimulation and enhanced nutrition interventions provided by LHWs through home visits and community group sessions. The interventions were randomized across LHW catchment areas in rural Sindh. The enhanced nutrition intervention provided micronutrient supplementation and additional nutrition education. Measuring children at six, 12, 18 and 24 months of age, neither intervention has significant effects on WAZ, whereas

> 46 Using an earlier round of similar data and the same empirical strategy as OPM (2009), Douthwaite and Ward (2005) find that LHWs have a significant positive effect on modern contraceptive use.

> 47 In a qualitative study, Lhussier et al. (2012) indicate that the use of certain formal information-gathering methods by LHWs to identify the issues and needs of intended beneficiaries and to design appropriate interventions raised selfreported knowledge on child feeding and care practices for a sample of mothers in KPK.

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