Published in Dawn, March 30th, 2016
ONE of the many contradictions of our society is between its loud avowal of its love of the ‘family’ institution and its devaluation of woman, the pivotal figure in the family. Not only do we look down on women inside the family, we give two hoots about women who commit themselves to door-to-door healthcare services for the women and children of the family. No wonder the issues being faced by lady health workers — job security, timely payment of wages and supplies of kits and medicines —remain to be addressed fully by the state.
Recently, while briefing a monitoring team, Tharparkar district officials shared that one of the reasons for the 2014 local health crisis was the collapse of the Lady Health Programme after devolution in 2010. The federal government stopped the funds and the Sindh government did not allocate resources. The 642 lady health workers and 22 lady health supervisors, whose services were spread over 42pc of the total area of the district, were neither provided with supplies nor given wages, while the remaining 58pc of the district was deprived of the benefits of the Lady Health Workers’ Programme.
Earlier this month, lady health workers in Karachi staged a sit-in near Chief Minister House against the delayed payment of salaries and for an improved service structure.
The Lady Health Workers Programme, instituted in 1994 by then prime minister Benazir Bhutto, is considered one of the largest and most successful community-based primary healthcare initiatives in the world. The lady health workers’ role has received recognition by global health bodies for improving Pakistan’s maternal and child health indicators.
Their job is tough: each worker, who has a minimum of eight years of schooling, is responsible for 1,000 people, or 150 homes, and visits five to seven houses daily. She is trained for 15 months in the prevention and treatment of common illnesses, spends three months in the classroom followed by 12 months of on-the-job training. She carries out over 20 tasks related to promotive, preventive, curative and rehabilitative services, including family planning services, antenatal referrals and immunisation services. Currently, more than 130,000 lady health workers reach out to 60pc to 70pc of the country’s population residing in rural and low-income urban areas.
Perhaps if it was not a collective struggle for their rights, the lady health workers would have continued to suffer injustice ie a paltry wage of Rs3,000 per month, no benefits and an insecure job. It was the death of a health worker during childbirth that compelled Bushra Arain, a lady health supervisor, to rebel against the irony: health providers’ own deprivation of health facilities and the absence of decent work conditions. She mobilised the health workers and founded the All Pakistan Lady Health Workers’ Welfare Association in December 2008.
By early 2009, each district had a baji, a dynamic activist health worker to prepare the cadre for struggle. In 2010, workers across the four provinces took to the streets to demand a wage increase and integration into regular health services. The phenomenon was unique: never before in Pakistan’s history had women workers exercised the right to ‘collective bargaining’ in any sector. When the federal and provincial government did not respond, health workers filed a petition in the Supreme Court which ordered the provinces in September 2010 to regularise their services and raise their wages from Rs3,000 to the national minimum wage level of Rs7,000 per month. By 2015 the minimum wage had been raised to Rs13,000.
But securing due rights has proved a tough task for health workers because hypocrisy and double standards reign supreme at all levels. From the governments’ approval to notification to allocation of resources to disbursement and implementing the rules of services, each step is resisted and delayed by the state officials. The provincial governments of Sindh, KP and Balochistan have reluctantly integrated the lady health workers’ position under the Civil Servants Act, 1973 and given grade V to lady health workers and grade VII to lady health supervisors. The Punjab government “…has turned out to be the worst”, Bushra tells me. “Instead of being integrated into the health services, lady health workers are governed by an authority.”
Even when the programme was functioning at the federal level, the budget allocation and releases were less than the programme requested each year. The national programme had four external evaluations by 2009. The systems were reviewed, gaps identified and remedial measures recommended. After devolution, no external evaluation of this vital 22-year-old programme has been undertaken by the provincial governments. It is in the best interest of the provinces that they raise the health budget, strengthen the programme and value the contributions made by the lady health workers.