"People will forget what you said, people will forget what you did, but people will never forget how you made them feel." - Pulitzer Prize winning poet Maya Angelou.

Azra Fatima*, a lady health worker (LHW) in Umerkot, Pakistan, lets out an audible sigh as she knocks on the door of her tenth home of the day. The house brings back an unpleasant memory of her previous visit, which ended with a stern rebuke from her boss, Naima*, a Lady Health Supervisor (LHS), for being behind on her target of reaching 100 houses a week.

The phone call left her feeling demotivated and made her anxious about visiting her next home. Despite the blow to her morale, Azra persisted but she remembers feeling that the phone call only made her job more challenging. A common complaint by LHWs like Azra is that they feel overworked and unsupported by their supervisors.

Moreover, an emphasis on meeting targets has led to a deep-rooted culture of blame with each cadre holding the other responsible for the system’s problems. “There’s a big missing piece in the LHW system and that is compassion,” says Ms Muneera Rasheed, a senior instructor in paediatrics and child health at Aga Khan University and director, patient experience of care, at Aga Khan University Hospital’s Children’s Hospital service line.

“Performance has become more important than people and LHWs feel as though they are just a means to an end. This affects their drive to meet the broader goals of the programme.”

The problem runs right through the system as LHSs, who supervise LHWs, complain about feeling demotivated as well. Azra’s superior, Naima, is subject to the same pressure of targets and she has come to believe that nothing will be achieved if she is not stern with the LHWs who report to her.

“While we may not be able to reduce the workload of LHWs and LHSs, a compassionate approach can change their perceptions about their job,” Ms Rasheed explained. “Care and empathy can turn around a person’s day and a motivated team of LHWs and LHSs can more effectively deliver essential door-to-door programmes that can address Pakistan’s healthcare challenges.”

After receiving a grant from the World Bank, Ms Rasheed built on her experience of working with paediatric nurses at Aga Khan University Hospital to develop a pilot intervention that would help achieve two objectives:

1. To build a culture of compassion throughout the LHW programme by applying its components to the programme’s daily operations.
2. To enable LHWs to deliver a new intervention, Early Learning Stimulation (ELS) – a set of educational activities designed to promote a baby’s cognitive and socio-emotional development – in partnership with a civil society group, Charter for Compassion (CfC), Pakistan.

Launching the combined intervention
The first three years of a child’s life represent a peak period of brain development and the success of the ELS initiative depends on the ability of LHWs to build a bond with a mother that leads to her altering her parenting style. Building this bond would not be possible without addressing the workforce engagement issues in the LHW programme, according to Ms Rasheed.

The combined intervention saw them bring together district health officers, LHSs and LHWs working in the same localities in the districts of Umerkot and Tharparkar. They noticed something unusual in the very first session of the programme: Despite working together for years, most people in the room had not met one another. Moreover, the few who knew each other had only been in touch in a formal capacity.

Developing empathy, gratitude and courage
After team members got to know one another in person, Ms Rasheed and her team conducted a role play exercise that saw supervisors swap places with subordinates, while other members played the characters of a mother and her child. After acting out a series of everyday challenges facing LHWs in the home, the trainers noticed a change in the room’s atmosphere. An LHS was taken aback by the experience and remarked that she had not realised how challenging an LHW’s work was. Similarly, an LHW noted that this was one of the few times that she felt confident, rather than afraid, of speaking to her supervisor.

Role play is a particularly useful way to improve group dynamics as it helps develop empathy and humility, which are crucial components of a compassionate mindset, explains Mr Aly Zubairi from CfC. He adds that the activity also highlighted the demotivating impact of public criticism and led to participants stating that they rarely appreciated one other and only ever communicated when targets were not being met.

Modelling humility, mindfulness and self-compassion
The intervention also consisted of on-job coaching and mentorship to model the value of supportive feedback. This led to LHSs understanding that reprimanding or interrupting an LHW in front of a mother impacts her credibility and affects whether she is taken seriously during follow-up visits. LHSs were guided about how they can offer emotional support or assist LHWs during visits that can promote the formation of bonds with the mother.

There were also important lessons about mindfulness for LHWs as they were reminded about the importance of self-care through a series of presentations. Every LHW has a set of homes with particular challenges and faculty told the audience of LHWs and LHSs that reprimanding oneself about past mistakes, or letting a single bad experience turn into anxiety about meeting targets, would impact their ability to bond with mothers in other homes.

LHWs were also urged to pay close attention to the challenges that many mothers living in large, joint families face. “It’s common for mothers to take offence to parenting advice especially if it’s given by a stranger in their own home,” Ms Rasheed told the participants. “But when an LHW takes the time to listen to a mother and empathise with their challenges, you can see the mother feels at ease in her presence. A mother immediately becomes more receptive to messages about health and she often emulates the kind, attentive behaviour from the LHW in her interactions with her child.”

Early Learning Stimulation
The second component of the intervention involved LHWs and LHWs applying the elements of a compassionate approach in order to introduce parents to ELS. LHWs were informed about the best ways to discuss the importance of regularly interacting with a child and stimulating him/her through play-based activities. Participants were shown how to keep a child engaged while bathing him/her or while feeding complementary foods. LHWs and LHSs also learnt how simple household items such as bottles and stones could be used to produce toys that capture a child’s attention.

Embedding a culture of compassion
Since the first session, follow-up programmes have been run every two months that have benefited over 320 LHWs and 50 senior members of staff, including LHSs, to date. Faculty remain in touch with LHSs to guide them on incorporating the components of compassion in their evaluations of LHWs and in updating LHW job descriptions to ensure that these practices take root in the broader programme.

The early results of the programme are positive with one LHW noticing such a significant change in her supervisor that she asked her whether she had returned from pilgrimage (Hajj).

“The LHW programme’s success lies in parents remembering and enacting what LHWs demonstrate during their visits,” Ms Rasheed added. “Health care is both a science and an art and compassion is a vital tool that can build trust, keep frontline staff committed to enhancing our healthcare system and help convince communities across the country to change their lives for the better.”

The intervention concluded in February 2020. The grant covered capacity building sessions in 10 union councils in the districts of Umerkot and Tharparkar. The team is eager to build on the intervention’s success by seeking funds for its expansion to other parts of the country.

* Names have been changed to protect the individual’s identity.

This article was first published on 18 November 2019 on the AKU website.