A broken workforce

On the UN’s Human Development Index, Pakistan occupies a pitiful rank. It perches on one of the lowest rungs on education and health indicators. If our performance in the recent past is any guide, the country is unlikely to progress much even by the end of this decade.

On the health front there is an extreme shortage of doctors, nurses and trained paramedical staff across the country. Even in a majority of private clinics and hospitals, one would hardly find properly qualified and trained health professionals and workers.

In this dire state of affairs, the role of lady health workers (LHWs) becomes fairly significant. The credit for the establishment of this workforce goes to the second government of Benazir Bhutto from 1993 to 1994. Being a woman and having close contact with the people, she knew what it meant for a woman to be in need of health assistance.

Prior to that, no civilian or military government had ever thought of creating a job category that would give employment to women as lady health workers and also cater to the needs of millions of women who had no access to health facilities. Now after nearly three decades of its establishment, this lady health workforce is playing its due role but faces tremendous problems.

LHWs serve women in both rural and urban areas especially in maternal and child health issues. In urban areas they provide health assistance mostly to slum communities by coordinating efforts with traditional birth attendants and midwives.

LHWs try their best to ensure that all mothers and children receive adequate care. Now Public Services International (PSI) has launched Pakistan’s first online interactive documentary experience that provides critical insights into the lives of LHWs.

PSI is a global union federation of workers in public services and serves as an international voice for public services and for workers and unions which deliver these services. There is a need in Pakistan to organize all workers in both private and public sectors.

Forming an integral part of public services, LHWs stand on the frontlines of Pakistan against all infectious diseases and save thousands of lives every day. The documentary about LHWs that PSI has developed highlights that they provide basic healthcare services to underprivileged communities in rural and low-income urban areas.

Their role has been so crucial in polio vaccine dispensation that they have regularly risked their own lives while being a target of militants who do not even hesitate to kill these workers and their security providers. Post-natal awareness and healthcare for rural mothers, with health education and promotion become a primary area of responsibility for these LHWs.

The documentary tells the tale of a woman called Haseena who narrates her story of how she became an LHW against all odds. The documentary comprises a series of episodes; ‘Behind the mask: Pakistan’ is a key episode focusing on the struggle that healthcare workers face especially in Pakistan. The documentary chronicles the challenges and the impact of Covid-19 on the lives of LHWs highlighting the work of Haseena and her colleagues who formed the All Sindh LHW and Employees Union (ASLHWEU) to advocate for better working conditions and wages.

With ‘Behind the Mask: Pakistan’, PSI is also campaigning for flood relief and the restoration of the health-risk allowance for LHWs. It calls for the provision of a service structure for them which is lacking at the moment. It is so disappointing to note that despite the critical frontline role of LHWs in the fight against diseases such as polio, cholera, and Covid-19, they continue to face harassment and have to function in terrible working conditions and low pay, especially in the face of inflation and wage stagnation. These are the issues that mainstream media rarely pays attention to.

Over the years, many LHWs have retired or left their jobs for various causes but there has been a lack of new hiring despite increased needs. The silver lining is that despite threats as polio workers, there are girls and women ready to join the LHW workforce, but the governments both at the federal and provincial levels have failed to initiate any new hiring.

Those who are already working have been facing vaccine shortages and gender inequality in terms of wages and working conditions. LHWs also lack adequate recognition from society, and were acknowledged for the fact that they continued working during the Covid-19 pandemic and even during the lockdown periods.

In this context, the ‘Behind the Mask: Pakistan’ episode focuses on key issues such as access to basic health services including vaccines, and the ILO Convention 190, which seeks to protect people from harassment and violence at work. The problems in hiring and the service structure also get coverage in the interactive documentary.

Since harassment is a major issue that LHWs have to deal with in their everyday work, watching the movie gives an insight into these problems. These women receive low salaries, and the health-risk allowance that the government offered during the pandemic is no more available to them despite being constantly at risk.

LHWs keep dealing with patients who suffer from infectious diseases, and that is good enough justification to pay them the health-risk allowance. Lack of funding is no good excuse for stopping that allowance that has put these LHWs in an extreme financial condition, and they can barely eke out a living with their meagre salaries.

Our state priorities have been focusing elsewhere, while neglecting people and social service workers alike has placed Pakistan as one of the lowest countries on human development. Recent devastating floods have compounded the problems even more with additional health crises in the affected areas posing new risks for LHWs.

The floods displaced nearly eight million people and damaged and destroyed more than two million houses – and nearly 1,500 health facilities and also wiped out a large part of people’s livelihoods. This has resulted in dangerous levels of malnutrition in expecting mothers who are likely to give birth to even more malnourished babies.

With this dire situation, frontline workers have been struggling to address the immediate crisis of displaced people while the spread of water-borne diseases and limited medical supplies continue to create further hardships for flood victims and LHWs who are striving to do their best.

We must not forget that the floods also affected a huge number of LHWs through displacement and illness. The documentary also sheds some light on the continuous protest of Pakistan’s healthcare workers to demand the resumption of the risk allowance with provision of service structure.

Unfortunately, the government responded by arresting and persecuting those who protested. The use of force in such matters is a highly condemnable act but the government instead of accepting the demands of health workers keeps targeting them.

Last Labour Day (May 1, 2023), the All Sindh LHW and Employees Union organized a rally in collaboration with PSI and the Workers Education and Research Organisation (WERO) in Hyderabad.

Some of the prominent people who have been spearheading these protests are doing a commendable job. They include Ms Haleema Laghari and Shama Gullani – president and general secretary of ASLHWEU – Mir Zulfiqar – GS of WERO – Qazi Khizar – vice-chairman of the HRCP – and Pushpa Kumari who is a well-known human-rights defender. They demand health insurance, social security, maternity leave, overtime and gratuity which are a fundamental right of the LHWs. The government must listen to them.

The writer holds a PhD from the University of Birmingham, UK. He tweets @NaazirMahmood and can be reached at:

mnazir1964@yahoo.co.uk