To our knowledge, this is the first study from Pakistan that focused on the LHW's work related stress and various factors contributing to it. It has clearly shown that over a quarter (26%) of the LHWs of the National Programme are mentally distressed. In addition to the administrative issues like inadequate amount and irregular disbursement of salary, and inadequate and irregular supply of medicine and other supplies, the rest of the 'causes for concern' are related to communication and interpersonal skills. The study has also established that a large proportion of health workers of this important public health program are not satisfied with their job because of the perceived absence of professional development and lack of career path.
A motivated workforce has been described as central to any health system. The improvement of human resource management in the health sector has been recommended in order to achieve millennium development goals (MDGs) . The third party evaluation of LHW Programme  also mentioned the need to improve quality of the work through improved management of the workforce. To achieve this, LHW's own opinion about the factors contributing to their job satisfaction/dissatisfaction must be studied. The qualitative nature of our study has enabled us to gain some insights in this area. At the same time, this qualitative study conducted in one sub-district has obvious limitations and is only suggestive at best.
The potential role of CHWs in improving community health has been acknowledged especially in resource poor countries. Haines et al  have described that owing to the inverse relationship of density of health workers (doctors, nurses, midwives) with maternal, infant and under 5 mortality; coupled with high cost of training doctors and nurses and the low use of services based in health facilities in many areas, there is a possibility to make substantial health gains from the use of community health workers. The Task Force for Scaling up Education and Training for Health Workers  recommended improving education of these workers through quality assurance programs and urged international action to scale up the production of quality health workers.
Other studies have also reported areas for improvement in the structure and performance of CHW programs including the LHWP of Pakistan. The low salary and lack of career path was highlighted by Afsar et al  as a reason for job dissatisfaction among the LHWs. Mumtaz et al.  reported abusive hierarchical management structure, disrespect from male colleagues, lack of sensitivity to women's gender-based cultural constraints, conflict between domestic and work responsibility and poor infrastructural support as the important problems faced by female primary health care workers from their study conducted in 1998 when the program was only four years old. Our study suggests that the disrespect from male colleagues and conflict between domestic and work related responsibility has improved while the other factors remain the same.
Douthwaite & Ward  found that the LHWP succeeded in increasing the use of modern contraceptives by rural women. According to them women served by LHW were significantly more likely to use a modern reversible methods than women in communities not served by LHW after controlling for various individual and household characteristics. They advocated for continuation of providing doorstep services through community-based workers to achieve universal access to safe family planning methods. Our study suggests that communication on family planning is still perceived as a difficult area by these workers and, while the programme should be continued, some interpersonal communication (IPC) capacity building measures are needed to further improve performance and outcomes.
Multifaceted interventions (e.g. training plus supervision) which address multiple determinants of performance have been recommended  to improve CHW performance. We add that improvement in remuneration; clear career path and improved administration are also required. In addition, empowering communication techniques should be built into the training and on-going supervision processes to improve the effectiveness of the community health workers.