Despite playing an important role in the community, lady health workers face myriad of problems. They are struggling hard to get their due rights. You! takes a look…
Developing countries like Pakistan face a lot of healthcare challenges. With inadequate health care facilities; few government hospitals, poor infrastructure and lack of professional doctors and nurses, the health status of Pakistan is below average. According to the World Bank statistics, Pakistan’s under-five mortality remains the highest among the South Asian countries except Afghanistan. In many rural settings, a significant percentage of births take place at home, usually attended by a dai (midwife). In the absence of skilled birth attendants, many mothers and children die at the time of their birth.
With an aim to provide essential primary health services in rural and urban slum areas, lady health worker programme (LHWP) was devised in Pakistan in 1994. Commonly known as Lady Health Workers, (LHWs), the programme was started with a staff of nearly 30,000 women. Over the years, the programme has expanded to more than 125,000 employees deployed in all districts of the country. They serve as the cadre that links first-level care facilities to communities.
Women from local communities, with at least 8 years of formal education, undergo 6 months of training to deliver care in the home, and each LHW is responsible for a population of about 1000 (i.e. approximately 200 families). The curriculum for the LHW’s programme includes: promotion of antenatal care, iron and folate use in pregnancy, immediate new born care, cord care and promotion of breast feeding. LHWs act as liaison between formal health system and community. To disseminate health education message to their community on hygiene and sanitation. LHWs provide essential drugs for treatment of minor ailments like diarrhoea, malaria, acute respiratory tract infection, intestinal worms and contraceptive materials to eligible couples.
Each Lady Health Worker is attached to a government health facility, from which they receive training, medical supplies, a small allowance and supervision.
Despite playing an important role in the community, LHWs face a lot of problems including extremely poor working conditions without wages, long hours, no clear job description, uncertainty of tenure and lack of safety while on the field. Other challenges include low-quality LHW training, poor supervision, inadequate supply systems (especially for drugs and contraceptives); lack of timely payment of salary; sexual harassment, lack of proper security during polio vaccination campaigns, denial of maternity leave and broken-down medical facilities. In order to raise their concerns, LHWs formed an association in 2009, the All Pakistan Lady Health Workers Association (APLHWA). They started a national movement for the regularisation of their jobs as public servants. From time to time they organise protest rallies, press conferences, sit-ins and nationwide media campaigns.
When 2008 was declared as the year of lady health workers, LHWs started their struggle for their inclusion in the health system as a regular employee, with proper salary and a regular contract of employment. In 2010, the LHWs staged a sit-in in front of the parliament house. In 2011, LHWs from across the country staged a historic sit-in at the Sindh Punjab border. Later, the movement took the country by storm as LHWs from Karachi to Khyber to Azad Kashmir protested at various places.
In February 2012, while they were protesting at the Karachi Press Club, many lady health workers were wounded and got suffocated due to heavy police shelling causing the miscarriage of a LHW from Nawabshah. While showing solidarity with their sisters in Karachi, LHWs from Punjab staged a sit-in on March 26, 2012, and faced torture of police, many were wounded. The then Chief Justice of the Supreme Court Iftikhar Muhammad Chaudhry took a suo moto action. A struggle spanning over two and a half years finally materialised and in 2014 orders were issued to regularise all LHWs with effect from 2012. The verification process took another two years and they received appointment letters in 2016. The arrears of the past four years were also paid to them.
In October 2020, despite pandemic, LHWs renewed their struggle with a sit-in in Islamabad, for giving them a proper service structure, retirement benefits and quota for deceased employees’ son or daughter. LHWs’ job scale is BPS-5 while LHW Supervisors’ scale is BPS-7, but their salary difference is of only Rs 1000, as LHW get Rs 29,000 while the Supervisors Rs 30,000. A supervisor supervises the work of 25-60 plus LHWs, while one LHW looks after the population of 1000 in rural areas and 1000-1500 in urban areas.
“At the moment, Pakistan has a total of 130,000 LHWs. There are around 22000 LHWs in Sindh while the province needs at least 80,000 LHWs, as quantum of work and geographical coverage has increased but we don’t get any additional allowance, food, care or transport to reach our place of work,” updates Shama Gulani, General Secretary of the All Sindh Lady Health Workers and Employees Union (ASLHWEU), which is the first union to be registered with the Labour Department. “Article 17 of the Constitution of Pakistan guarantees the right of every citizen to form associations or unions and LHWs used their right,” adds Shama.
“LHWs have a checklist to fulfil, including pre-and post-natal care, and immunisation of the child till he turns 3 and FP awareness for the next pregnancies. Many LHWs are still not getting their salaries for the past 22 months as their identification process is still underway,” says Haleema Zulqarnain, President of the Union.
“In Punjab, acting supervisors don’t get any allowance for double burden of work. LHWs in Sindh get a coronavirus allowance of Rs 17000 per month, which is denied in other provinces. Since new appointments are not being done, supervisors do extra work, with no additional allowance, technical support,” laments Haleema. “Supervisory allowance is given to supervisors of Sindh only and not in Punjab. The retired employees haven’t been given any pension, social security, or gratuity which other government servants enjoy. Only those who will retire in 2022 will get the pension,” she informs.
In 2017, ASLHWEU and Punjab Lady Health Workers Union got an international affiliation with the Public Services International (PSI), a global federation of the trade unions, representing more than 20m working men and women from 154 countries of the world, including Sri Lanka, Bangladesh, Nepal, India and Pakistan.
“PSI provides technical and financial support to LHWs union, build their capacity and facilitate in their lobbying with the government,” elucidates Mir Zulfiqar Ali, Executive Director, Workers Education and Research Organization (WERO), who brought this international affiliation to Pakistan.
“In 2017, we attended conferences in Nepal and Japan, and shared our experiences with community workers, unions from across various countries. During the pandemic we continued sharing and learning from each other through Zoom meetings,” tells Haleema.
Contrary to Pakistan, LHWs in India and Nepal, where they call them Public Health Volunteers, haven’t been accepted as part of public health system and are denied facilities and service structure. Covid-19 brought new challenges for the lady health workers around the world, which resulted in the preparation of a joint charter of demands by lady health workers of Pakistan, India and Nepal with the help of PSI, WERO.
“We lobbied with the government to include LHWs in the planning as they, like doctors and paramedics, are the frontline workers and undertaking coronavirus monitoring, FP and vaccination work as well as mother and child health care during pandemic. We demanded to recognise them as public health workers; include them in decision-making processes, provide occupational safety and health protection, ensure dignity at work, care for the workers, and establishment of a people-centred healthcare system,” explains Zulfiqar.
“Sexual harassment is the main issue. In case of any harassment, the victims usually keep quiet as there is no complain mechanism in place, especially in rural areas. So, no complain is registered. We want the government of Pakistan to ratify ILO’s Convention C-190 on Sexual harassment so that the national laws could be brought in tune with this convention,” voices Zulfiqar.
Recently, a seminar was organised by the All Sindh Ladies Health Workers and Employees Union (ASLHWEU) in collaboration with the Public Services International (PSI) and Workers Education and Research Organisation (WERO), at Karachi Press Club.
The seminar was held in connection with the problems faced by lady health workers (LHWs) who presented a charter of demands (COD) to the PPP-MNA Shahida Rahmani. She promised to raise the issues mentioned in COD in the assembly and would strive to solve them at the earliest. Journalist Moniza Inam declared the charter of demand a great milestone in the long struggle of LHWs, started in 2011.
Chairperson Sindh Commission on the Status of Women (SCSW), Nuzhat Shirin while acknowledging the services of health workers called for their recognition at national level said,
“As an important segment of the public health system, LHWs fill a huge gap, especially in facilities-deprived rural areas. Government should ensure provision of personal protective equipment (PPE) and personal security of LHWs who go in the field as frontline soldiers.”
“We also do election duties as security guards, presiding officer or Assistant presiding officer. In 2018 election, security guards were not paid any allowance for their risky job,” told Naseem, a LHW from Sindh.
The struggle of LHWs is still on as Haleema Zulqarnain puts it: “Even the recent success wasn’t easy, it is replete with countless sacrifices and constant struggle, which paid off, though late, but we will not rest till all our demands are met.”
