A hidden ‘army’ is on the frontlines of immunization in Pakistan

What it takes to manage 400,000-plus polio eradication workers

By Etelka Lehoczky

You may never have seen a community health worker. You may not even have heard the term before. But these individuals, many of them volunteers, play increasingly important roles in health care systems around the globe. And they’re essential to Rotary’s health initiatives — especially the fight against polio and other diseases.

Community health workers are usually women. They have expansive personal networks that enable them to identify and connect with underserved people living around them. They often go from house to house, providing basic medical interventions and advice. In many countries, they’re the main workforce administering polio vaccinations.

Another common focus of their work is maternal and child health, but even that can involve immunization support, says Svea Closser, a medical anthropologist and a professor at Johns Hopkins University in Baltimore, Maryland, USA.

“They will do some basic checks, prenatally, and often accompany women to the hospital when it’s time to give birth. Then they’ll follow up after the baby is born to encourage the mother to get the baby vaccinated,” says Closser, who has studied community health workers in Ethiopia, India, Nepal, Pakistan, and other countries. “And besides working with the polio campaigns in almost every country, they will also provide additional support for other vaccines: getting people to the places where the vaccines are being given, allaying parents’ fears about vaccines, things like that.”

Administering vaccines and educating people about the need for them are among the most important parts of a community health worker’s job. That’s particularly true in Pakistan, one of only two countries where the wild poliovirus still circulates. (The other is Afghanistan.)

More than 400,000 community health workers are deployed across Pakistan, including in the most remote regions. It’s a squad that’s second in size only to Pakistan’s real army, says Israr Ul Haq, who has a key role in overseeing the vast group. He’s a social and behavioral change specialist for UNICEF, one of Rotary’s core partners in the Global Polio Eradication Initiative.

Ul Haq recently talked about the demands of finding, training, and managing nearly half a million community health workers. In Pakistan, they’re divided into frontline workers and social mobilizers.

Israr Ul Haq, Social and Behavioral Change Specialist, UNICEF Islamabad, Pakistan

Q: What do frontline workers and social mobilizers do?

A: Frontline workers go from house to house to vaccinate. Social mobilizers take the message of the importance of polio vaccination — and not just polio vaccination, but also the health and well-being of children and mothers — to the community.

Q: Do you need to find workers who live in every community, all over Pakistan?

A: Yes. It is very important for people to have social and emotional attachments to the workers who end up at their doorsteps. Social mobilizers should be well known in the community, so we have to pick from the community. It’s not like we can bring in somebody from outside.

Q: Why not?

A: It’s like, “The people from within us would never harm us.” We need to win people’s trust. We need for people to understand why we stress the importance of polio vaccination more than anything else. That social buy-in is very important. After 28 years of this program, more than 95% of people open their doors to get their children vaccinated.

Q: What qualifications do you look for when recruiting health workers?

A: We predominantly work with females. We have a conservative society where men from other families are not allowed to go inside people’s houses. Access to mothers is very important, and it’s next to impossible in some areas for men to talk to the mothers. But in far-flung areas where it is very difficult for females to travel, it’s very difficult to get females to do this work. And then we end up getting males from within those societies.

Q: Are there other challenges in recruiting workers in remote areas?

A: The workers should be educated enough to read and write, but it depends on the literacy rate in the area. In areas where we have low literacy rates, we have taken on older females who could not read and write but were known in their communities.

A health worker marks a child’s finger after vaccinating him at a community hall. In Pakistan, community health workers are the backbone of the fight against polio. Songal Gadap, Karachi, Pakistan. 3 August 2022.

© Rotary International

Q: What skills and information do the workers learn?

A: We do an orientation on polio, polio vaccination, and routine immunization. Then they are trained in the basics of human dialogue and community listening. We spend a lot of time training people in how to listen. We are also training them in a package of key family health care practices.

We’ve recently started a training approach we call the “golden triad,” which is between the person in charge of an area, the frontline worker, and the social mobilizer. They’ll do some exercises, they’ll build trust, and they’ll ensure that they actually help each other achieve their jobs. This training is now going to be every six weeks, so practically all our social mobilizers will be retrained and refreshed regularly.

Q: Are the workers paid? If so, what do they earn?

A: They are paid around US$150 per month.

Q: How many vaccination campaigns do the frontline workers implement each year?

A: On average, six to eight campaigns will be conducted per year, but not all are conducted across the whole country. The number across the whole country may vary between three to four per year, whereas the remaining are smaller campaigns or outbreak responses in limited geographies. [About] 45.2 million children were vaccinated in the last major campaign.

Learn more about the female health workers employed by the GPEI in Pakistan.

— April 2025