The PPP government had promised in its 2013 manifesto to increase the outreach of Lady Health Workers’ services to 100 percent of rural areas and to urban slums.
Initiated in 1994, the Lady Health Programme has nearly collapsed in Sindh after the devolution of the health sector. As soon as the 18th Amendment was enforced, the Federal Government stopped lending funds to the health sector while the Sindh government refused to allocate resources to the program. When the Tharparkar district in Sindh, was hit by drought and the subsequent death of hundreds of infants and children due to malnutrition and unavailability of timely treatment, the officials conceded that one of the reasons for the 2014 health crises in Tharparkar was due to the deterioration of the Lady Health Workers’ program. About 642 Lady Health Workers and 22 Lady Health Supervisors were not given supplies and wages.
The Lady Health Programme has been recognised globally as a successful community-based primary health care system. During Benazir’s tenure as Prime Minister, and later, for many years, this programme was deemed vital for the improvement of maternal and child health indicators.
The job description of a lady health worker comprises of Consultation, Motivation, Help and Reference. Each lady health worker visits five to seven houses per diem. She is responsible for attending to 1,000 people or 150 households. The workers are hired after eight years of minimum basic education, they are given 15 months of training in the preventive treatment of common illness, three months of course work, and 12 months of on-the-job training.
There are a total of 24,086 Lady Health Workers in Sindh. These workers are able to cover just 42 percent of the areas, while the remaining 58 percent is deprived of the benefits of this programme.
The irony is that this programme shared the vision of its leader Benazir Bhutto, and yet the government of Sindh has mercilessly ignored it. Not only are these women paid a meagre salary of Rs.16,200 per person, the practice of unpaid salaries for three to four months at stretch is rampant. The situation had become so abysmal that the workers themselves were deprived of basic health facilities, which led to the death of a lady health worker during childbirth. This led to the creation of Pakistan Lady Health Workers Welfare Association in December 2008. Bushra Arain, who is the Central President of the organisation, has given the above information to Truth Tracker.
This was the beginning of the struggle of the lady health workers against a system that deprived them of their legitimate demands of integrating them into the regular health service sector, and providing them with decent working conditions. The sit-ins and protests made little difference to the government and eventually, Bushra had to file a petition in the Supreme Court. It was in 2012 that the Supreme Court ordered the Federal and the Provincial government to resolve the issue of salaries of the lady health workers without delay.
Though the Sindh government had reluctantly integrated the Lady Health Workers’ position under the Civil Servant Act, 1973, the issue of timely payment of wages, says Bushra, has not been addressed fully. “We have been paid past four months’ salary.” “It was a chore to get a notification regarding the allocation of resources, their disbursement and the implementation of rules by the Sindh officials. They would try to resist at every level and every step,” she explained.
The situation of the Lady Health Worker Programme had not been very satisfactory, even when it was managed at the Federal level. The allocation and disbursement of resources had been inadequate and few and far between. Up until 2009, four external evaluations had been held to identify gaps and remedial measures in the programme. However, since the devolution, not a single evaluation had been carried out in Sindh to sustain the 22-year-old programme.
Sindh Assembly Deputy Speaker, Shehla Raza, conceded that Pakistan People’s Party had been unable to do anything substantial for the Lady Health Workers. She told Truth Tracker that during one of the Population Planning meetings, it was revealed that not only is Pakistan’s population increasing at a phenomenal rate, but maternal deaths have also risen proportionally. She further informed that it had been decided that in the new plan, the LHW would be given a central role in managing both family planning and maternal health issues. About the delays in salaries of the LHW, she said that it is imperative that not only salaries should be given in time but they should also be increased. “We have decided to hire more LHWs so that our promise to penetrate far and wide into Sindh is fulfilled.”
Arif Alvi, a member of National Assembly from Sindh and leader of Pakistan Tehreek-e-Insaaf, condemned the PPP government for being so callous towards a programme that was considered to be the dream of Benazir Bhutto. “Not only has the government in Sindh been unable to prevent children from contracting polio, it has brought the entire health system down due to improper policies that lead to corruption,” said Alvi. According to Alvi, “It will be a long way before the government in Sindh get serious regarding the health issues of their citizens.”
Sehar Abbasi, a member of Sindh Assembly, echoed identical doubts that coincide with those of Alvi. She said that her party, PML-N, had stood in solidarity with the Lady Health Workers during their protests and sit-ins. “The government is not serious about making impactful changes in the health sector or in the Lady Health Workers’ Programme,” said Abbasi.
Bushra Arain, Central President, Pakistan Lady Health Workers’ Association, said that many times they were forced to provide extra services either during the election days or to administer polio drops. “Administering Polio drops is not part of our job description but we are forced to do it nonetheless.” She further added that the government is only hiring 138 new Lady Health Workers in Sindh.
Dr Qaisar Sajjad, Secretary General, Pakistan Medical Association, told Truth Tracker that the government does not prioritise Healthcare as an important issue on their agenda. Regarding Lady Health Workers, he said, “They form the backbone of the healthcare system, especially in a country like ours, where 70 percent of the population lives in rural areas, women health workers become even more important.” “Many issues pertaining to women could be solved if the Lady Health Workers’ programme is completely implemented in Sindh. Population,” he said. Dr Sajjad said, “The population has been increasing exponentially while the government of Sindh was doing nothing. With the help of Lady Health Workers, we can control population since these women have the leverage to have contact with the families they visit and could, therefore, persuade them to adopt family planning measures.”
Sajjad said that during the 2010 floods, when his team went to rural Sindh, it found women having 15 or 16 children. “When we asked the reason behind so many children, they would reply that at the end of the day, hardly seven or eight children survive,” Sajjad said. He said that the rural women had no idea how to take care of their own health or their children’s. Pakistan is one of the countries with the highest maternity and child mortality rate.
According to a report launched in 2015 by Save the Children Pakistan, titled ‘The Urban Disadvantage’, the Maternal Mortality Rate in Pakistan is 276 per 100,000 live births and the underwrite child mortality rate is around 89 per 1,000 live.
The doctor concluded his remarks by saying, “We have destroyed the health sector, and along with it, the Lady Health Worker Programme.”
PPP has failed to keep its promise of increasing the coverage of LHW services to 100 percent of rural areas and to urban slums. In fact, the Sindh government has destroyed the programme due to negligence and lack of interest in providing proper Healthcare services.