Pakistan has a population of 153 million [1]. It has an organized infrastructure for delivering health care even in small villages but these health care centres are devoid of medicines, equipment, doctors and trained paramedics. There is one doctor, one nurse and one bed for 1400,3261 and 1531 people respectively. 76% deliveries occur at home[2 ] .Main part of budget allocated for health goes to teaching institutions and major hospitals of federal and provincial capitals; very little is left for towns and small villages. Doctors are not willing to work in small cities, towns and villages. They prefer government hospitals of federal and provincial capitals. This is justified if they work in a proper manner on merit on rotational basis but this seldom happens. They use all means to stay in these hospitals until some more resourceful replace them [8].

Pakistan is a country where health facilities exist between the two extremes, i.e. very sophisticated as in Aga Khan University Hospital, to almost very primitive as in remote basic health care units. The access of people to medical facilities also varies greatly from very privileged to absolutely devoid. Annual growth rate (2003) is 2.6%. Dependency ratio per 100 in 2003 is 82 whereas it was 87 in 1993. Percentage of population aged 60+years in 2003 is 5.7 whereas it was 5.6 in 1993. Total fertility rate in 2003 is 5, it was5.8 in 1993[1]. Per capita GDP in international dollars (2001) is 2,146.Total expenditure on health as % of GDP (2001) is 3.9 Per capita total expenditure on health at average exchange rate (US$), 2001 is 16. General Government expenditure on health as % of total expenditure on health, 2001 is 24.4. General Government expenditure on health as % of total general government expenditure, 2001 is 3.5. Private expenditure on health as % of total expenditure on health, 2001 is 75.6.Sources of private health expenditure are Prepaid plans as % of private expenditure on health, 2001=0 and Out-of-pocket expenditure on health as % of private expenditure on health, 2001=100 [3].

Both the government and private health services are available to people. Our upper and middle classes have full access to government as well as private health facilities. The real problem is with the masses and the people that live below the poverty line. People usually avoid government hospitals for primary care because of overcrowding, difficulty in getting due attention and admission even in emergency situations, casual and non-serious behaviour of doctors, more than one male doctor examining the female patient at one time and the fear of a crowd of medical students present at time of examination [8].

It consists of [9];

A)Medical Services

1-Doctors
The minimum qualification is M.B., B.S. They should have a valid registration with Pakistan Medical & Dental council.

2- The Health Workers {Paramedical Staff}
The following categories are usually included under this term in Pakistan;
i) Classified Nurse: The female must have passed high school examination in science to get admission into this course. She takes a four years course in Nursing during which she has to reside in hospital. Due to proper education and training, they work ethically and are aware of importance of working in own limits.

ii) Lady Health Visitor (LHV): The female must have passed high school examination in science to get admission into this course. She takes a short course of about two years and she is basically trained in womens health and midwifery.

iii) Locally Trained Nurses: This is the most available variety. Some of them are high school graduates but most of them are usually middle passed or less. They are neither adequately educated nor properly trained.

iv) Lady Health Worker (LHW): This type was produced by government to induce health education and create awareness about womens health. They are usually only middle pass and a local resident.

v) Midwives or Traditional Birth Attendants (TBA): In Pakistan, TBAs are absolutely uneducated and non-trained. 81% of deliveries are conducted by them.

vi) Male Paramedics
25 % of this group are qualified but 75% are just locally trained in clinics and pathology labs. We do not have an appreciable number of life saving paramedics.

vii) Highly Trained Mobile Paramedics
This is very recent addition to the system. At the moment, these are only found in army, Navy, Air force and in some Flying Squads. These are fully qualified.

B) The Alternate Medical Services
These include;
1- Registered Hakims (traditional healers)
2- Registered Homeopaths
3- Traditional Quacks
4- Religious Quacks

A major part of our budget goes to defence. 35 million people live below poverty line [4]. Despite all efforts for reduction of poverty, more and more people are going below the poverty line. Our population is growing rapidly. There is a rapidly increasing burden on the government funded health care system. There would be an additional requirement of 175,000 doctor and 40,000 nurses by 2010[5].

We have to shift more care from hospital to primary care; most important in this context is Antenatal care. The total population of Pakistan (in thousands) was 141,256.2 in the year 2000. It would be 181,384.7 in the year 2010 and 227,781.1 in the year 2020. Total Numbers of people (from age group 0 to 60+ years) requiring daily care was 8,292.1(in thousands) in the year 2000. It is expected to be 10,908.2(in thousands) in 2010 and 14,254.5 (in thousands) in year 2020. This means the total Numbers of people (from age group 0 to 60+ years) requiring daily care would increase by 32% in the year 2010 and 72% in the year 2020 as compared to year 2000 [6]. During the year 1996-97, 36 % of pregnant woman received 1+ Antenatal visit and 16 % received 4+ Antenatal visits. 17 % births took place in health facilities. In the year 1998, 20% of births were attended by skilled health care personnel [7]. In the year 2003, PROBABILITY OF DYING (per 1000) in under age 5 m/f was 98/108 and between ages 15 and 60 years m/f was 225/199[1].

Health workers play the largest part in the delivery of primary care [10]. They are the first contact of people who not only seek their help for primary care but also in acute emergencies and accidents. There is no organized platform for Health Workers in Pakistan.

There is an urgent need to train and organize Health Workers in this country. They have to play a vital role in the delivery of primary care in coming years because of tendency of people to avoid hospitals. Health Workers lack adequate knowledge and skills especially regarding antenatal care and safe childbirth. They have to address their shortcomings[8].

In fact there is no organized system of involvement of Health Workers in health care in primary care. We have to establish an effective system of Paramedical Care. There is an immediate need for establishment of a Platform for Health Workers {Paramedics} that should;

a) Set a code of ethics and lobby for legislation about their involvement in health care services.
b) Should organize educational and vocational training for them.
Most important in this regard is to explore new avenues to get a more educated and more understanding batch of new health care workers [8].

I take the liberty to describe our efforts towards this end in our community-Shamsabad. On this "World Health Day", we launched a program for organization and training of Health Workers {Paramedics} in antenatal care.[13]

A-Object:
1- To evolve a platform for training of existing and new health workers on CME pattern.[12]
2- To create and maintain a "Data Base" of existing and new health workers so that all recent knowledge and skills could be conveyed to them.
3- To evolve an easy to understand manual [ both in English & Urdu] for education and training of existing and new health workers
4- To help the health workers to evolve their own organizations that could strive for them in accordance with the following guideline principals of WHO--- ;
i) Cater for their education& training
ii) Provide support and protection to them
iii) Enhance their effectiveness
iv) Tackle imbalances and inequalities

B-Who would be benefited by our training
Our doors are open for all existing and new health workers. We are specially focusing on Female Health Workers initially but we will help all regardless of their age, gender, race, religion, creed and method of treatment. All health concerns like doctors, nurses, midwives, TBAs, Hakims, Homeopaths, laboratory technicians, dental technicians, and community health workers are welcome.

C-What is our strategy for Training?

Step-1: Identification and registration of existing and new health workers for training
Step-2: Determination of Extent of training
Step-3: To impart training
Step-4: To evaluate the candidates after completion of training

D-What would be the extent of training?

There are three levels of education and training depending upon the extent of curriculum.

The syllabus in our case {Delivery Technicians} includes:
In my opinion, every care provider must have very clear understanding and skills of;
Monitoring of Vital Signs {Pulse, BP, Temperature and Respiratory rate}& weight recording, Cardio-Pulmonary Resuscitation, Sterilization and Asepsis, Very brief Surface anatomy of woman and foetus, Brief Basic knowledge about Menstrual cycle, Contraception-----both regular & emergency, and Examination of Breast.

The Main Syllabus includes:
Nutrition, Anemia, Brief Anatomy (maternal & foetal), Menses, Family planning (both regular & Emergency), Gynaecological examinations, Antenatal Care, Rhesus incompatibility, Pre-Eclampsia, Eclampsia, CPR, Foetal growth & well being, Vaginal bleeding during pregnancy (Ectopic pregnancy, Miscarriage & abortion, Antepartum Hemorrhage, Post Partum Hemorrhage, Placenta Praevia, accidental Haemorrhage, Hydatidiform mole), Twin pregnancy, Labour (normal & abnormal), Various methods of delivery (Normal delivery, mal-positions, hygiene, avoiding trauma, analgesia, and danger signs and how to manage hemorrhage), Postnatal care of mother (Normal and danger signs such as endometritis, bleeding, Eclampsia), Puerperium, Brief knowledge of D&C, E&C, Resuscitation of newborn, Immediate Post-natal care of the child, breast feeding, vaccination,. Etc

Primary Level of Training: This is mean for community health workers. It would be in form of short and basic courses.

Incentives for learners: No big incentives are required; just certificates of appreciations would be sufficient.

Secondary Level of training: This is meant for those who intend to adopt it as profession.

Incentives for learners: Certain incentives like certificates plus some financial support in form of scholarship are necessary.

Tertiary level of training: This is full and advance training to evolve life saving paramedics

Incentives for learners: Definite incentives like certificates, financial support during learning plus employment opportunity are essential.

E-What would be the Infra-structure?

To avoid unnecessary expenses, I am using my clinic for imparting this training.

F-Who will train?

I, Dr Manzoor Butt, have started the work with the intention to evolve a new batch of "Delivery technicians". We have started training in how to do antenatal care and conduct safe birth. We will enrol more relevant persons as the activity continues.

G-How the training would be imparted?

Firstly, the learners would be taught through audio-visual lectures. They would be given opportunity to learn on patients. The training and skills in how to conduct the labour would be given on Manikin. This Manikin is donated by Emeritus Professor Dr John Beasley of Wisconsin [ 15 ]

H-Who will monitor & evaluate?

My seniors, Dr Christopher Rose of U.K [ 14 ], Ms. Lesley Pocock, executive director of WorldCME-Australia[ 12 ] and Emeritus Professor Dr John Beasley[15] would guide through and monitor the activity.

I-Who would certify the successful candidates?

WorldCME-Australia would initially certify the successful candidates until the WorldCME/Pakistan starts operation.[12]

J-What resources would be required?

We have started the activity on our own.It is our aim to make our clinic a model clinic-----engaged in health education of community and involved in training and evolution of new health workers.
To execute all these ventures on large scale, more resources are required. Our government, International agencies like WHO, UNICEF, and national and international NGOs should contribute to achieve this goal. I believe we must put more and more stress on organized Antenatal care at community level because women, at least in this country, have a very low tendency to go to hospitals [11]. Our aim should be to identify and anticipate mode of delivery in most of our cases. This will help in timely referral and avoidance of long labour. We should encourage and help the care providers of a community to establish and organize a network of their own which should work under guidance of Family Physician or the nearby hospital [8].

K- How the activity could be extended to other areas

We will encourage other family Physicians to replicate these activities in their own communities. Some incentive would be required.

L- How the activity would be sustained?

These activities just require support and guidance. These do not need lots of funding. The expenses could be catered by the Family Physicians organizing these trainings.